published by the assistive technology industry association (atia) · 2018-08-28 · volume 11,...

Published by the Assistive Technology Industry Association (ATIA)

Jennifer L. Flagg

Editor-in-Chief

Kate Herndon &

Carolyn P. Phillips

Associate Editors

Volume 11Summer 2017

Maximizing the Benefits of Evolving Assistive Technology Solutions

CopyrightÓ2017AssistiveTechnologyIndustryAssociationISSN1938-7261

Volume11,Summer2017

AssistiveTechnologyOutcomesandBenefits|MaximizingtheBenefitsofEvolvingAssistiveTechnologySolutions

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AssistiveTechnologyOutcomesandBenefitsMaximizingtheBenefitsofEvolvingAssistiveTechnologySolutions

Volume11,Summer2017

Editor-in-Chief:JenniferL.Flagg

CenteronKT4TT,UniversityatBuffalo

PublicationManagers:VictoriaA.Holder

ToolsforLife,GeorgiaInstituteofTechnology

ElizabethA.PersaudToolsforLife,GeorgiaInstituteofTechnology

CarolineVanHowe

AssistiveTechnologyIndustryAssociation

AssociateEditors:KateHerndon

AmericanPrintingHousefortheBlind

CarolynP.PhillipsToolsforLife,GeorgiaInstituteofTechnology

CopyEditors:BeverlyNau

MelissaSnider

LouisianaAssistiveTechnologyAccessNetworkAssistiveTechnologyOutcomesandBenefits(ATOB)isacollaborativepeer-reviewedpublicationsoftheAssistiveTechnologyIndustryAssociation(ATIA).EditingpoliciesofthisissuearebasedonthePublicationManualoftheAmericanPsychologicalAssociation(6thed.)andmaybefoundonlineatwww.atia.org/atob/editorialpolicy.ThecontenthereindoesnotreflectthepositionorpolicyofATIAandnoofficialendorsementshouldbeinferred.EditorialBoardMembersandManagingEditors:DavidBarnesManagingDirector,DavidBarnesAccessandInclusionServicesRussellT.CrossDirectorofClinicalOperations,PrentkeRomichCompanyAnyaEvmenovaAssistantProfessor,AssistiveandSpecialEducationTechnology,GeorgeMasonUniversityLoriGeistResearchAssociate/ProjectDirector,CenterforLiteracy&DisabilityServices,UNCChapelHillBenSatterfieldResearchConsultant,CenterforATExcellence,ToolsforLifeatGeorgiaInstituteofTechnologyMelissaSniderExecutiveProgramManager,LouisianaAssistiveTechnologyAccessNetworkJoyZabalaCo-Director,NationalCenteronAccessibleEducationalMaterials(AEMCenter)DirectorofTechnicalAssistance,CAST

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PeerReviewersforATOBVolume11MaximizingtheBenefitsofEvolvingAssistiveTechnologySolutions

TheEditorialBoardwouldliketothankthepeerreviewerswhogenerouslydonatedtheirtimeandtalenttoreviewingmanuscriptsforthisVolume11ofATOB.

PattiBahrJoseBlackorbySamCreech

SarahEndicottSarahEkartLynnGitlow

TeresaGoddardClaireGreer

PenelopeHatchDaveHershberger

AnnHirshJosephLaneKristaMullen

TracyRackenspergerPatriciaWright

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AssistiveTechnologyOutcomesandBenefitsEditorialPolicy

AimandScopeAssistiveTechnologyOutcomesandBenefits,publishedbytheAssistiveTechnologyIndustryAssociation,isanopenaccess,peer-reviewedjournalthatpublishesarticlesspecificallyaddressingthebenefitsandout-comesofassistivetechnology(AT)forPersonswithDisabilitiesacrossthelifespan.Thejournal’spurposeistoadvancetheATindustryby(a)fosteringcommunicationamongstakeholdersinterestedinthefieldofAT,includingmanufacturers,vendors,practitioners,policymakers,researchers,consumerswithdisabilities,andfamilymembers;(b)facilitatingevidence-baseddemonstrationsandcase-baseddialogueregardingeffectiveATdevicesandservices;and(c)helpingstakeholdersadvocateforeffectiveATdevicesandservices.AssistiveTechnologyOutcomesandBenefitsinvitesforconsiderationsubmissionsoforiginalpapers,reportsandmanuscriptsthataddressoutcomesandbenefitsrelatedtoATdevicesandservices.Thesemayinclude(a)findingsoforiginalscientificresearch,includinggroupstudiesandsinglesubjectdesigns;(b)marketingresearch related to AT demographics, or devices and services; (c) technical notes regarding AT productdevelopment findings; (d)qualitative studies, suchas focus groupand structured interview findingswithconsumersandtheirfamiliesregardingATservicedeliveryandassociatedoutcomesandbenefits;(e)pro-ject/programdescriptionsinwhichAToutcomesandbenefitshavebeendocumented;(f)case-basedreportsonsuccessfulapproachestoservicedelivery;and(g)consumerperspectivesonATdevicesandservices.SubmissionCategoriesATOBwelcomesscholarlycontributions.However,manystakeholdersengagedinthefieldofATdonothaveanacademicbackground.ATOBoffersauniqueopportunityforthesestakeholderstocontributetheirexper-tiseandexperience in thecontextofachievingsuccessfuloutcomesandbeneficial impacts.ATOBunder-stands that many potential authors may lack experience in authoring papers for peer-reviewed journalpublication.Therefore,theATOBEditorialBoardispleasedtoofferassistanceinpreparingandrefiningrele-vantsubmissions.Articlesmaybesubmittedunderthreecategories—VoicesfromtheFieldArticlessubmittedunderthiscategoryshouldcomefromprofessionalswhoareinvolvedinsomeaspectofAT service delivery with persons having disabilities, or from family members and/or consumers withdisabilities.Submissionsmay includecasestudies,projectorprogramdescriptions,approachestoservicedelivery,orconsumerperspectivepieces.Allsubmissionsshouldhaveaclearmessageandbewrittenwithenoughdetailtoallowreplicationofresults.VoicesfromtheIndustryArticlessubmittedunderthiscategoryshouldcomefromprofessionalsinvolvedindevelopingandmarketingspecificATdevicesandservices.Casestudies,design,marketingresearch,orproject/programdescriptionsareappropriateforthiscategory.VoicesfromAcademiaArticlessubmittedunderthiscategoryshouldcomefromprofessionalsconductingresearchordevelopment

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inanacademicsetting.Submissionsarelikelytoincludeapplied/clinicalresearch,casestudies,andproject/programdescriptions.TypesofarticlesthatareappropriateincludeWithineachofthevoicescategories,authorshavesomelatituderegardingthetypeofmanuscriptsubmittedandcontenttobeincluded.However,ATOBwillonlyacceptoriginalmaterialthathasnotbeenpublishedelsewhere,andisnotcurrentlyunderreviewbyotherpublishers.Additionally,allmanuscriptsshouldoffersufficientdetailtoallowforreplicationofthedescribedwork.Applied/ClinicalResearchThiscategoryincludesoriginalworkpresentedwithcarefulattentiontoexperimentaldesign,objectivedataanalysis,andreferencetotheliterature.CaseStudiesThiscategoryincludesstudiesthatinvolveonlyoneorafewsubjectsoraninformalprotocol.DesignThiscategoryincludesdescriptionsofconceptualorphysicaldesignofnewATmodels,techniques,ordevices.MarketingResearchThiscategoryincludesindustry-basedresearchrelatedtospecificATdevicesand/orservices,demographicreports,andidentificationofATtrendsandfutureprojections.Project/ProgramDescription.Thiscategoryincludesdescriptionsofgrantprojects,privatefoundationactivities,institutes,andcentershavingspecificgoalsandobjectivesrelatedtoAToutcomesandbenefits.ApproachestoServiceDeliveryThiscategoryincludesdescriptionsoftheapplicationofassistivetechnologyinanysetting(educational,voca-tional,institutional,home-life)toimprovequalityoflifeforpeoplewithdisabilities.ConsumerandCaregiverPerspectivesThiscategoryoffersanopportunity forproductendusers, familymembers,andcaregivers tosharetheirexperiencesinachievingsuccessfuloutcomesandbenefitsthroughtheapplicationoruseofATdevicesandservices.MandatoryComponentsofallarticlesAuthorsmustincludeasectiontitledOutcomesandBenefitscontainingadiscussionrelatedtooutcomesandbenefitsoftheATdevices/servicesaddressedinthearticle.Authorsmustincludeashortdescriptionofthearticle’stargetaudience,andindicatethearticle’srelevancetothattargetaudience.Authorsmaydescribetheirworkasitrelatestomorethanoneaudience,andshouldspecifythevaluethateachgroupmayderivefromthework.PublishingGuidelinesEachmanuscriptmustreflectthestyleguidelinesofthePublicationManualoftheAmericanPsychologicalAssociation(6thedition,2009).

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Manuscriptsshouldbenomorethan25pagesinlength(double-spaced),includingreferences,tables,andfigures.Duetotheelectronicformatofthejournal,allsubmissionsshouldbesubmittedasemailattachmentsinaMicrosoft®Wordformat.SeedetailedManuscript PreparationGuidelines forAuthors formore informationon formatting require-mentsandsubmissioninstructions.ForMoreInformationPlease see ATOB’s Editorial Policy at http://www.atia.org/at-resources/atob/ for details regarding thesubmission and review process, ATOB’s copyright policy, and ATOB’s Publication Ethics andMalpracticeStatement.

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AssistiveTechnologyOutcomesandBenefitsMaximizingtheBenefitsofEvolvingAssistiveTechnologySolutions

Volume11,Summer2017TableofContentsINTRODUCTIONTOATOBVOLUME11:MAXIMIZINGTHEBENEFITSOFASSISTIVETECHNOLOGYSOLUTIONS viii

JENNIFERL.FLAGG&CAROLYNP.PHILLIPS ASSISTIVETECHNOLOGYOUTPACINGDISEASEPROGRESSION:ALONGITUDINALCASESTUDY 1

DARRENGABBERT IMPACTOFSELF-REGULATEDSTRATEGYINSTRUCTIONINTEGRATEDWITHSOLOLITERACYSUITE 17

KARENERICKSON LORIGEIST PENELOPEHATCH

OPINIONPARAGRAPHWRITINGINTERVENTIONFORSTUDENTSWITHSIGNIFICANTDISABILITY 29

PAMELAJ.MIMS CAROLSTANGER ROBERTPENNINGTON WENDEEWHITE JULIESEARS NANCYSTRICKLER

TECHNOLOGYBENEFITSTOELDERLYWITHINFIRMITIESINFUNCTIONALMAINTENANCEPROGRAMS 47

RICHARDD.STEELE LISAHAYNES LELANDWHEELER

COMMUNICATIONANDDEVELOPINGRELATIONSHIPSFORPEOPLEWHOUSEAUGMENTATIVEANDALTERNATIVECOMMUNICATION

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CHRISKLEIN USEOFMOBILETECHNOLOGYBYADULTSWHOUSEAUGMENTATIVEANDALTERNATIVECOMMUNICATION:VOICESFROMTWOCOUNTRIES

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DIANENELSONBRYEN JUANBORNMAN JOHNMORRIS ENIDMOOLMAN F.MARKSWEATMAN

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IntroductiontoVolume11:MaximizingtheBenefitsofEvolvingAssistiveTechnologySolutions

JenniferL.Flagg,ATOBEditor-in-ChiefCarolynP.Phillips,ATOBAssociateEditor

WelcometoVolume11ofAssistiveTechnologyOut-comesandBenefits (ATOB).The theme for this is-sue,“MaximizingtheBenefitsofEvolvingAssistiveTechnologySolutions”advancesourvisionforATOBtobeaneffectivetoolforknowledgetransfer,track-ingtrends,andhighlightingnewinformationontheoutcomesandbenefitsofassistivetechnology(AT)forpersonswithdisabilities.ThethemewaschosenfollowingtheEditorialBoard’sannualreviewoftheATIAConference’sresearchstrand.Wenoticedthatmanyofthe2016conferencesessionswerefocusedonwaysthatmainstreamtechnologies,suchastab-letsandsmartphones,canbeusedbothinplaceofand as complements to AT devices. At the sametime, there were a number of sessions exploringnewdevelopmentsrelatedtodedicatedATdevices.As a result, this issue considers a full range ofpromising technology solutions employed by andfor peoplewith disabilities. Read on for details ofthesixarticlesfeaturedhereinATOBVolume11.

Theissuekicksoffwithtwovoicesfromacademia.FirstupisDarrenGabbertwithhisarticle,“AssistiveTechnology Outpacing Disease Progression: ALongitudinalCaseStudy.”Mr.Gabbertdescribesaprocess that was used to determine appropriateworkplaceaccommodationsforanindividualwhosefunctionalneedsandjobrequirementswerechang-ing frequentlydue toprogressionofadisease.Heexplainshowthatprocesswasusedtoidentifythe

individual’sfunctionalneedsandthenfindsuitablesolutions, taking advantage of improvements inavailablemainstreamand assistive technology.ATspecialists,employers,andpeoplewithdisabilitieswillappreciatethesystematic,cyclicalnatureoftheAT assessment and evaluation process,which canbeusedittoaddressissuesofincreasingfunctionallimitationsandchangingjobrequirements.

NextupisanarticlefromKarenErickson,LoriGeist,and Penelope Hatch entitled “Impact of Self-Regulated Strategy Instruction Integrated withSOLOLiteracySuite.”Theauthorsshareresultsandinsightsfromtheirstudyintohowliteracysoftwaremight combine with a self-regulated strategydevelopmentapproachtoimproveeducationalout-comes for struggling writers in elementary class-rooms. The authors’ thorough discussion of theirwork and the positive outcomes the studentsachieved will be valuable for administrators andinstructors seeking to integrate these or similartechnologiesandstrategiesintheirclassrooms.

The next two articles share perspectives from ATindustrystakeholders.In“OpinionParagraphWrit-ing Intervention for Students with SignificantDisability,” Pamela Mims, Carol Stanger, RobertPennington,WendeeWhite,JulieSears,andNancyStrickler describe amethod for using reading andwriting apps on tablets to improve the opinion-

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writing skills of students with intellectual disabili-ties.TeachersandATspecialistsare likelytovaluethe authors’ detailed description of theimplementationofthemethodinaclassroomset-ting. Additionally, this article offers the reader anexcellent example of a successful university-industry collaboration. Such partnerships can pro-videacademicswithfundingforATefficacystudies,while also supplying industry with objective evi-denceofaproduct’seffectiveness,combinedwithvaluablefeedbackfromitsendusers.The second industry perspective comes fromRichardSteele,LisaHaynes,andLelandWheelerintheir article, “Technology Benefits to Elderly withInfirmaries inaFunctionalMaintenanceProgram.”This piece describes a collaboration between arehabilitationservicesproviderandanATmanufac-turer,whereonlinespeechandlanguageexerciseswere incorporated intoexisting functionalmainte-nanceprogramsatlong-termcarefacilities.Theau-thors’findingsindicatethatamongolderadultswithcognitive impairments and communication chal-lenges,improvementswereseeninbothexpressivelanguage and memory. Long-term care providersandfacilitymanagerswillfindthisinformationuse-fulfortheirpatients,andfamilymembersofelderlylong-termcareresidentsmaywishtousethesefind-ingstoadvocatefortheadoptionofthistechniqueandtechnologyfortheirlovedones.Two voices from the field round out this issue ofATOB. Chris Klein’s contribution, “Communicationand Developing Relationships for People who useAugmentativeandAlternativeCommunication,”isaconsumer perspective piece, written from hisexperienceasalong-timeuserofanaugmentativeand alternative communication (AAC) device. Mr.Kleinconveysthecriticalimportanceofcommunica-tion in relationship-buildingand calls for a shift inthefocusofcurrentthinkinginAAC,awayfromskill-building for the purpose of meeting educationalmandatesandtowardstheinherentbenefitsofso-cialcommunication.Tothatend,hedescribesaser-vice-oriented approach of mentorship by and forpeoplewhouseAACdevicesasonewaytoaddress

the challenges involved in making that shift. Mr.Klein’sarticlewillbeofinteresttoAACdeviceusersthemselves,theirfamilymembersandfriends,AACproduct manufacturers, and AAC device serviceproviders.Lastly, Diane Bryen, Juan Bornman, John Morris,EnidMoolman,andF.MarkSweatmancontributedan article entitled “Use of Mobile Technology byAdults Who Use Augmentative and AlternativeCommunication: Voices from Two Countries.” Theauthorsdescribetheiruseofsurveystoinvestigatehow people who rely on AAC are using mobiletechnologyandwhatbarrierstheyfaceindoingso.Based on the survey findings, they presentrecommendations for researchers who may beinterestedinstudyingsimilartopics,fordevelopersin both the mobile technology and AT industries,andforpeoplewhouseAACdevices.As you read, consider the distinctions andcommonalitiesthatemergefromthisdiversesetofpapers.Thesurfacedistinctionsareeasytodiscern;thecontentsvaryfromimprovingthewritingabilityof young students, to enabling social communica-tionamongusersofAACdevices,toprovidingeffec-tiveaccommodationsforindividualswithdisabilitiesintheworkplace,toincreasingpositiveoutcomesoffunctional maintenance programs for agingindividuals.Youmaynotice,though,thatfromjustbeneath the surface, some commonalities shinethrough.By itsnature,each investigationfeaturedin this volume relies upon the use of advancedtechnology–computers, smartphones,andstand-alone AAC devices – regardless of whether thetechnologyisconsideredmainstreamorassistive.Inall of these cases it is technology that is enablingpeopletomovebeyondfunctionallimitationstoen-gage inmeaningful activities and to achieve theirpersonalgoals.ATistransformational.However,wemust also remain mindful of the assessment andimplementation strategies, the training, and theinformationdisseminationapproachesthatallowustomaximizethebenefitsoftheseevolvingATsolu-tions.ThevalueoftheAssistiveTechnologyIndustryAssociationinhelpingpeopletoachievetheseaims

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cannot be overlooked. It is through continueddiscussionandcollaborationthatwecanseethesepositive outcomes spread throughout the ATcommunity.Inthatspirit,ATOBencouragesATstakeholderstoread,learnandshare,andtoactivelyparticipateinthis conversation. ATOBoffers severalways to dojustthat.Wecontinuetoseekoutauthorswhocanshare innovative practices, aswell as peoplewithdisabilities who can give voice to their firsthandexperiencewithassistive technology.Peer review-ersarealsovitaltoATOB’ssuccess,andwewelcomeinterested individuals to volunteer for this [email protected],asanopen-access journal, ATOB encourages its readers tosharethesestudiesandstorieswithothers.Letuscontinue the conversation and carry this positivemomentum forward into reaching even greatermilestonesonthepathtowardinclusionandfullac-cessforall.DeclarationsThis content is solely the responsibility of the au-thorsanddoesnotnecessarilyrepresenttheofficialviewsofATIA.Theauthorsreportednofinancialornon-financialdisclosures.AcknowledgementsThecontentsofthisintroductoryarticleweredevel-opedunderagrant fromtheNational InstituteonDisability, Independent Living, and RehabilitationResearch(NIDILRR),grantnumber90DP0054-01-00.NIDILRR is a Center within the Administration forCommunityLiving(ACL),DepartmentofHealthandHumanServices (HHS).Thecontentsof thisarticledonotnecessarilyrepresentthepolicyofNIDILRR,ACL,HHS,andyoushouldnotassumeendorsementbytheFederalGovernment.

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AssistiveTechnologyOutpacingDiseaseProgression:ALongitudinalCaseStudy

DarrenGabbert

Sr.BusinessOperationsAssociate,DivisionofInformationTechnologyUniversityofMissouri–Columbia

AbstractRapidgrowth indedicatedassistiveandaccessiblemainstream technologies has heightened aware-nessofthecriticalimportanceofappropriateassis-tive technology assessment and training. This im-portancehasunderscoredtheneedfortechnologyassessment to be a dynamic, continuous processthatmaintainsfocusonfunctionaldeliverables.Thispaperpresentsalongitudinalcasestudydescribingkeystosuccessfullyaccommodatingapersonwithaseveremobility impairmentovera27-yearperiod.Special emphasis is given to achieving levels ofproductivityconducivetocompetitiveemploymentwithinanITcustomerserviceorganization.Acyclicalmethodology referred to as theAssistive Technol-ogy Optimization Process (ATOP) is defined, de-scribed and illustrated. As demonstrated by thiscase study, the ATOP offers much scaffolding totrack, plan, and integrate changing technology tomeetchangingexpectationsinthefaceofchangingcapabilities.Severaltrendscanbeobservedwithinthecourseofthestudywheretechnologybenefitsoutpaceddiseaseprogression.Forthestudysubject,hisemployer,and the fieldofassistive technologythatissuccess!Keywords:assistivetechnology,assessment,mobil-ity,musculardystrophy,spinalmuscularatrophy

IntroductionThebenefitsofassistivetechnology(AT)largelyde-pend on the successful matching of specific userneedstospecifictechnologies.EveryATpractitionersoon realizes this matching must be done amidstchanging parameters. Advancing technologies,progressive user limitations, and evolving stake-holderexpectationscanallposepositiveandnega-tiveimplicationsontheATassessmentprocess.TheUniversity of Missouri’s Adaptive ComputingTechnologyCenterhasestablishedasystematicap-proachgearedtowardthevariablenatureofmakingAT system recommendations. This cyclicalmethodology referred to as theAssistive Technol-ogy Optimization Process (ATOP) is defined, de-scribedand illustrated througha longitudinal casestudy.Thisstudydemonstrates implementationofdesktop and mobile computer technologies usingtheATOPtoguidetheprocessovera27-yearperiodforanindividualwithsevereandprogressivemobil-ity limitations. Special focus is placed on changeover time, including: a) meeting changes inuser/technology performance expectations; b)compensating for progression of mobility limita-tions;andc)leveragingadvancesinmainstreamandassistivetechnologies.Manyassessmentmethods in the fieldofassistive

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technology are non-standardized, lengthy, subjec-tive,andrequiresubstantialclinicalexperienceofamultidisciplinary team (Jenko et al., 2010). TheATOPisdesignedtoovercomesomeoftheseweak-nessesthroughapracticeofcontinuous,functional-basedevaluations.ATOP’sfocusonfunctionaltaskperformancekeepstheprocessrelevanttodesiredoutcomes, while its continuous practice revealstrendsshowingeitherpositiveornegativeefficacyof accommodations. Ineffective assessment prac-tices lieat theheartofstatisticswhichsuggestATdevice abandonment may be as high as 30%(Federici, Meloni, & Borsci, 2016;Mumford, Lam,Wright,&Chau,2014;Phillips&Zhao,1993).Someassessmentmethodsattempttoremediatethisbyplacingheavyemphasisonuserself-determination.Thetheorybeingthatenhancedself-determinationleads to more positive outcomes (Wehmeyer,2004). While this is a fundamental part of ATOP,self-determination must be supported by expertknowledgeofATbestpractices.Therightparame-tersmustbeprovidedtoensureinformeddecisionmaking.OnestrengthATOPoffersisitscapacitytotrendredundantaccessmethodswhichleadtouserdiscovered best practices. For example, a one-handedtypistmighthaveanadaptedkeyboard,aswell as, speech recognition as concurrent accessmethods.ATOPcyclesshouldindicatewhichisusedmost,underwhatcircumstances,andatwhatlevelof proficiency. This practice of “discovered bestpractice” is demonstrated repeatedly throughoutthecasestudy.Anothernoteworthyassessmentapproachisbasedontheconceptofresponseefficiency.Responseeffi-ciencysupportsATselectionbyassessingfourfac-tors that have been identified as significantlyinfluencing efficiency: response effort, rate ofreinforcement, immediacy of reinforcement, andquality of reinforcement (Mumford et al., 2014).Thesecriteriareflectsomestrongsimilaritiestothesix criteria used in ATOP, however, the ATOP isstrictlytiedtotaskperformance.Thisresultsinthemodel’sability toaddressredundantaccessmeth-ods,whichisafundamentalstrengthofATOP.

TargetAudienceandRelevanceThe five-phase assessment cycle described in thispaperoffersaneffectivemethodologyforevaluat-ing computer based technologies. The goal ofmaximizingbenefits,whileaccommodatingchangeinmultiplefactorsiscommontoalldisabilitytypes.Whilethedegreeofvariabilitymaydifferfromoneusertoanother,theassessmentcycleremainsrele-vanttooptimizingcapabilitiesinallapplicationsofAT.TheATOPoffersbothserviceprovidersandATusersasystematicapproachtocontinuousimprove-mentthatcanbeeasilydocumented.ThisapproachalsobuildsanATuserhistoriesrevealingbestprac-tices that may benefit other users with similartechnologies.AssistiveTechnologyOptimizationProcess(ATOP)TwofundamentalprinciplesguidingtheATOPare:1)settingtaskspecificgoals;and2)exercisingclientself-determination.Regardingtheformer,youmustknowwhatthetargetisbeforeyoucanaimforsuc-cess. Too often AT providers (and even AT users)equate computer access with improved quality oflife and increased ability. In terms of AT success,however,gainingaccesstotechnologyismoreofabeginning than an ending. Regarding the latter;technology only fosters self-determination if itachievesresultsthataremeaningfultotheenduser.For example, setting a goal of providing speechrecognitionasaprimaryinputmethodfallsshortofdefiningeither theneedor theaim. Incontrast,atask specific goal of using speech recognition tomanageandcomposeemails inMicrosoftOutlookprovidesameasureableobjectiveforsuccess,ade-fined context for training, and a functional andempoweringoutcomefortheuser.DeterminingthescopeofgoalstoincludeinanATassessmentdependson self-determination factorssuchastheuser’sneedforindependence,theirpre-ferredmethodsofcommunication,andtheireduca-tion/employmentperformanceexpectations.Whilegoals in any of these domains are influenced bynumerous outside factors as well as personal

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factors, the centrality of self-determination iscritical to both their definition and attainment(Steel,Gelderblom,&deWitte,2012).Usingthis foundation,wehaveconstructedafive-phase,cyclicalprocess(SeeFigure1)tomatchandoptimize AT to user goals. The first phase is thedevelopmentoftheinitialperformanceplan.Whenthisprocessisinitiated,taskspecificgoalsareidenti-fiedanddefinedbytheATprofessionalanduser.Phase1–PerformanceEvaluation officiallybeginswith a performance evaluation of theuser/technology match. In reality, however,performanceshouldbecontinuallymonitoredandthis phase should be invoked proactively.Undoubtedly, applying themodel in a rigid, linearmanner runs the risk of missed opportunities torespond to performance shortfalls outside ofscheduledevaluations.UnmetuserexpectationsinAT performance need to be recognized,communicated,andaddressed ina timelymannerto avoid user frustration and subsequenttechnology abandonment. For example, a

departmental operating system upgrade wouldlogicallyinitiateatargetedperformanceevaluationof software compatibility. Changing performanceexpectations can likewise initiate Phase 1 of theATOP.Identifyingmeasurable andmeaningful evaluationcriteria isaformidablechallengefor individualizedAT accommodations. Task-specific goals do, how-ever, lend themselves to a fundamentalmeasure-ablequestion:Cantheuseraccomplishatask?Butthe ability to accomplish a task is not necessarilysuccess.Sixevaluationcriteriathatareparticularlyhelpful in operationalizing successful task perfor-mance are speed, accuracy, fatigue, load, con-sistency, and satisfaction. While each of theseattributesmaybequantifiedwithsomeprecision,inmanycircumstancesordinalratingssuchaslow,me-dium,andhighprovidesufficientdefinitionfortheassessment.Speedistheexception,however,andratioscalingisbest for tracking progress. A common example istext input rate, which is measured in words per

Figure1.AssistiveTechnologyOpportunityProcess(ATOP)

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minute; or, text-to-speech output rate for thosedepending on auditory reading. Speed shouldalwaysbeviewedalongsideaccuracy.Anillustrativeexamplewouldbehighspeedbut lowaccuracy intextinput.Inthisexampletheresultmaybeanetlossoftimeandenergyexpenditureduetomakingcorrections,thusdiminishingoverallefficiencyanduserexperience.User fatigue is another multicomponent factor,comprisingbothfrequencyanddurationofthetask.Loadreferstothephysicaland/orcognitivedemandassociatedwithperformingthetask.Consistencyre-lates to the user’s ability to perform satisfactorilythroughoutthetaskandeachtimetheyundertakethetask.Andlastly,satisfactionconstitutesaposi-tive overall experience performing the task, usingthetechnology.Phase2–RecognitionofObstaclesandOpportuni-ties is a process that should be undertakenindependent of possible technology solutions.Evaluation criteria for each task, changes in theuser’s abilities, new or modified performanceexpectations,andadvancesinmainstreamorassis-tivetechnologiesareallpossiblecatalystsforATsys-tem changes. Obstacles and opportunities fromPhase2dovetailwithPhase3–AssessmentofSolu-tions,wheresolutionandoptimizationoptionsarestudied. This assessment phase of the process in-cludes: 1) Identifying recognized obsta-cles/opportunitiesthatcanbereadilyaddressed;2)researching solutions for unsolved issues; and 3)determiningtimingandfeasibilityforimplementingresearched solutions. When possible, multipletechnology solutions should be introduced asredundantsystems,thuspermittingthedegreeandrate of technology adoption to follow inherentbenefits. For example, someone with progressivemobility limitations may have a workstation withboth speech recognition and eyegaze capabilities.Which, where and when each is used will bediscovered by the user and optimized in futureATOPiterations.Phase4–TechnologyInterventionis the actual implementation of the technologysolutions with appropriate testing, training, and

adapting. And Phase 5 – Revise Plan brings theprocessbacktotheperformanceplan;documentingrevisions and targeting a future date of the nextevaluation.

CaseStudySubjectBackgroundThesubjectinthiscasestudyisa51-year-oldmalewith an advanced form of Muscular Dystrophycalled Type 2 – Spinal Muscular Atrophy. Thisgenetic condition affects the nerves that controlmuscle movement. Type 2 of this disease ischaracterized by moderate onset and progressiveweaknessinarms,legs,lowertorso,andrespiratorymuscles.Thesubjecthasusedapowerwheelchairfor mobility since adolescence. Navigation wasinitiallyviaajoystickcontrolledbyhisrighthand.By2005, disease progression had reached completeparalysis,withwheelchairnavigationaccomplishedthroughelectromyography(EMG)switchscanning.The subject has been ventilator dependent since2013.Thesubjecthasa4-yeardegreeinComputerScience,andwashiredintoafull-timepositionwithan IT organization in 1989. Subject continues towork within the same organization in a 50% full-timeequivalentcapacity.ATOPIterations:1989–2016Listed here are six iterations of the AssistiveTechnology Optimization Process that were con-ducted with the study subject between 1989 and2016. Each iteration presents highlights of all fivephases of the process: Performance Evaluating,RecognitionofObstaclesandOpportunities,Assess-mentofSolutions,TechnologyIntervention,andRe-vise Plan. Performance goals are listed as columnheadings within each iteration’s Functional GoalsMatrix. It should be noted that the subject’stechnical skillsandaptitude fromtheonsetof thestudy significantly contributed to continuousoptimization. This is most clearly seen in thesubject’scomfortlevelwithtechnologychange.Theresponsibility to initiateATOP iterationswould fallmoretotheATpractitionerininstanceswherethe

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ATuserpossesseslesscomputingskills.Accommodation (1989): Keyboard and MouseModificationsPhase 1 – Performance evaluation. The subjectseemed satisfied with one-handed typing on astandardkeyboard,anddemonstratedaninputrateof approximately 20 words per minute (Sp) withhigh accuracy (A). Moderate drop in efficiencyassociatedwithfatiguewasobserved(F).Standardmousewasunusableduetorestrictedrangeofmo-tion.Subjectcoulddialstandardpushbuttonphone,butcouldnotlifthandset.Phase2–Recognitionofobstaclesandopportuni-ties. Subject experienced significant difficultyanswering and hanging up phone. Access to bothApple andWindows operating systems was ham-peredbysubject’sinabilitytomanipulatethecom-puter mouse. Opportunity existed to reducekeyboarding load by accommodating one-handedkey combinations associated with modifier keys(e.g.shift,ctrl,alt).Phase 3 – Assessment of solutions. The followingissueswereaddressed:

• Work environment was not conducive tospeaker phone conversation. Gooseneck

armwithphonehandsetcradlecouldallowsubject to drive wheelchair to positionhandsettoear/mouth.Neededtofabricatealuminum lever to allow user to easilyopen/closethephoneline.

• Trackball could replace computer mouse,requiringsignificantlylessrangeofmotion.Becausethesubjecthadexcellentfinemo-tor movement, mouse pointer navigationcould be further enhanced by trackballsensitivity settings (i.e. reduce the ball-to-pointermovementratio).

• Installed Sticky Keys software utilities onboth Apple and Windows workstationswhichallowedsubjecttopresskeycombina-tionssequentially.

Phase 4 – Technology intervention. The followingsolutionswereimplemented:

• Introduce Gooseneck/lever phoneaccommodation.

• Introduce2Trackballs(AppleandWindowscompatible) with sensitivity adjustmentcapability.

• ImplementedStickyKeysonbothplatforms.Phase5–Reviseplan.Changesresulting fromthistechnology accommodation are indicated withinparenthesesinTable1.

Table11989FunctionalGoalsMatrixforKeyboardandMouseModifications

FunctionalGoals 1.Placeandreceivecalls

2.Manageandcomposeemailonamainframesystem;

3.Composewrittentextandgraphicsforusersupportdocumentation;

4.AccessAppleand Windowsoperatingsystems(mouse)

EvaluationCriteria

(Sp)eed One-handedtyping,20wpm

One-handedtyping,20wpm

(A)ccuracy High High Low(High)(F)atigue High(Low) Medium Medium High(Low)(L)oad High(Medium) Medium(Low) Medium(Low) High(Low)(C)onsistency Low(High) High High Low(High)(S)atisfaction Low(High) High High Low(High)

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Accommodation (1993): Transition to DiscreteSpeechRecognitionPhase 1 – Performance evaluation. Progression ofsubject’sneurologicaldiseasewasseeninincreasedfatigue for all functional goals, which is inverselycorrelatedwithsatisfaction.Allcriteria(Sp,A,F,L,C, S) supported an immediate intervention toaddress text entry (2, 3). Mouse control (4) wasfollowingsamedownwardtrend(F,L,C,S),thoughindicatorsshowedcontinuedviability(A,C,S).Tele-phone accommodation (1) was likewise losingground(F,S),butcontinuedtobeeffective.Phase2–Recognitionofobstaclesandopportuni-ties.Diseaseprogressionwascausingweaknessandshrinking range of motion. Advances in speechrecognition offered a keyboard alternative on theWindows platform. Mouse control via speechrecognition would be awkward. Availability ofspeechrecognitionontheAppleplatformwasverylimited.Phase 3 – Assessment of solutions. The followingissueswereaddressed:

• Speech recognition technology wasavailableforWindowsplatform,andwouldhave strong potential to increase speedwhile decreasing fatigue. Subject’s privateofficeofferedoptimumspeech recognitionenvironment. Windows system was tar-geted for composing text (speechrecognition offered awkward mousecontrol).

• Robust speech recognition technologywasnot available for Apple platform. VoiceNavigator system did offer speaker-dependent, discrete speech systemwith a1,000-word capability. This technologycould supplement existing trackballcapability with voicemacros for repetitivekeystrokes. Apple systemwas targeted forgraphicdesignandinternetbrowsing.

• Telephone accommodation was leftunchangedwitheyeon futureopportunitytointegrateintoWindowsworkstationafterspeechrecognitiontransition.


Table21993FunctionalGoalsMatrixforTransitiontoDiscreteSpeechRecognition

FunctionalGoals1.Placeandreceivephonecalls

2.ManageandcomposeemailonMicrosoftOutlookClient;

3.Composewrittentextandgraphicsforusersupportdocumentation;

4.AccessAppleandWindowsoperatingsystems(mouse)

EvaluationCriteria

(Sp)eed

One-handedtyping,9wpm(Discretespeech,pending)

One-handedtyping,9wpm(Discretespeech,pending)

(A)ccuracy Medium Medium High(F)atigue Medium High(Low) High(Low) High(Medium)(L)oad Medium High(Medium) High(Medium) Medium(C)onsistency High Medium(High) Medium(High) Medium(S)atisfaction Medium Low(High) Low(High) Medium

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• Dragon Dictate for Windows (speaker-dependent,discretespeech)introducedasahands-freeaccessmethod.

• VoiceNavigatoraddedtoApplesystemforgraphicdesignandinternetbrowsing.

Phase5–Reviseplan.Changesresulting fromthistechnology accommodation are indicated withinparenthesesonTable2.Accommodation (1999): Redefining PerformanceExpectationsPhase 1 – Performance evaluation. As a result ofdiseaseprogressionandotherhealthrelatedissuesthe subject’s performance expectations werereducedtocoincidewitha50%full-timeequivalentappointment. Telephone accommodation (1) hadcontinued to show diminished efficacy (L, C, S).Composingtext(2)viadiscretespeechrecognitionwas approximately 18 words-per-minute (Sp).Redefined functional goals were aligned withapplications supported the byWindows platform,thus removing the Apple technology from hisperformanceplan.Becauseworksitelocationwouldbe flexed between home and work, the need formobile computing accesswas added to functionalgoals(3)andwouldbeaddressedinthiscycle.

Phase2–Recognitionofobstaclesandopportuni-ties. Integrating new telephone accommodationintothespeechrecognitionsystemappearedtobethe best fit. Awireless headsetmicrophone couldfacilitate independent access to the home work-station.Accesstoaphysicalswitchfortogglingthemicrophoneon/offwouldbeneededtofacilitateus-ingoneheadsetforbothcomputerandtelephone.Laptopwithdockingstationcouldseamlesslyallowthesamesystemtosatisfybothfunctionalgoals2and 3. Opportunity explored to increase speechrecognition accuracy because of advances in thistechnology.Phase 3 – Assessment of solutions. The followingissueswereaddressed:

• Becauseofthesubject’slimitedpulmonaryfunction, upgrading from discrete tocontinuous speech recognition was notfeasible. Accuracy for continuous speechrecognition is heavily dependent on wordcontext, thusrequiringusers tospeak longphrases within single utterances. Trialsshowedpoorrecognitionaccuracybecausethesubject’sbreathcapacitycouldproduceonlytwoorthreewordsperutterance.

• AlaptopwithexpandedRAMwasidentifiedto meet speech recognition system

Table31999FunctionalGoalsMatrixforRedefiningPerformanceExpectations

FunctionalGoals 1.Placeandreceivephonecalls

2.ComposewrittentextandmanageinformationviaMicrosoftOfficesoftware;

3.Manageinformationandemailbeyondhomeworkstation

EvaluationCriteria

(Sp)eed Discretespeech,18wpm

(A)ccuracy Medium (Medium)(F)atigue Medium(Low) Low (Low)(L)oad High(Low) Medium (Medium)(C)onsistency Low(High) High (High)(S)atisfaction Low(High) High (High)

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requirementsandallowportability.• Home workstation needed to permit the

subject to come and go freely withoutrequiring assistance to engage the system(e.g. subject cannot be tethered toworkstation with wired headsetmicrophone).

• Nanopac CINTEX4 system identified toprovidehands-freecontrolofthetelephonevia the same wireless headset used forspeechrecognition.

• Afootswitchcouldbemountedunderneathworkstation desk and actuated by thesubjectelevatinghiswheelchair’spowerlegrests. Switch would toggle the speechrecognition’s microphone on/off. Speakingwhilethemicrophoneisinasleepstatefre-quentlycausesthemicrophonetoinadvert-ently wake up, an issue that would beexacerbated by the microphone’s sharedfunction between the computer and thetelephone.

• A wired headset microphone with noisereduction capabilities could be usedwhenlaptop is undocked and mounted on thewheelchair’slaptray.


• Primary workstation configured with alaptop anddocking station, externalmoni-torfor increaseddesktopworkspace,scan-ner for paperless workflow, and wirelessheadsetmicrophone (rechargeablewith 8-hourlife);

• Nanopac’s CINTEX4 hands-free telephonesystemintegratedwithspeechrecognition;

• Additionalwiredheadsetmicrophonewithnoise cancellation supplied for use whenlaptopisundockedandmountedonwheel-chairlaptray.

Phase5–Reviseplan.Changesresulting fromthistechnology accommodation are indicated withinparenthesesonTable3.

Accommodation (2005): Transition to ContinuousSpeechRecognitionPhase 1 – Performance evaluation. In light of thediscrete speech recognition software no longerbeing supported, and growing concern over thelikelihood of compatibility beyond Windows XP,continuous speech recognition was revisited.Advances in continuous speech recognition couldofferimprovementsinbothspeedandaccuracy(Sp,A),inadditiontothenumerousbenefitsassociatedwith using a supported, feature-rich technology.Subject’smobile solutioncontinued to show func-tional efficacy (Sp,A, F, L, C), but satisfactionwaslowduetobulkinessofthelaptopandtheprohibi-tive background noise associated with public set-tings. Alternative mobile solutions were studied.Telephone setup continued to be effective andsatisfactoryagainstallevaluationcriteria.Phase2–Recognitionofobstaclesandopportuni-ties. An advanced feature within the DragonNaturallySpeaking software allowed a pause be-tweenspokenwords,whichcould facilitateaccessdespite limited breath. Pocket PC/Smartphoneswere quickly becoming ubiquitous technologies,though largely unexplored for alternate accessmethods. Software developed in Switzerland ex-istedthatofferedsomedegreeofswitchscanningaccess.Phase 3 – Assessment of solutions. The followingissueswereaddressed:

• Trialswiththepausebetweenspokenwordssettonearly1secondpermittedthesubjectto inhale between pairs of words, thussimulating continuous speech recognition.SubjectcoulddictateentiresentencesthatDragonNaturallySpeakingwouldprocessasasingleutterancewithpercentof recogni-tionaccuracyintheupper-nineties.

• NoHandCom software showed strongpotentialforeffectiveswitchaccesstoWin-dowsMobileplatform.Developerwaswill-ingtoaddfunctionalitythatwouldmoveto-ward all device features being switch

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accessible.Mobiledevicecouldbeaccessedby the second switch output from theTinkertron EMG switch. Triggering of thisswitch occurs when muscle activity is de-tectedbyasingleelectrodeonthesurfaceoftheskin,andatriggersustainedformorethan2secondscausestheswitchtotogglebetween two outputs. In this case, switchoutput#1beingusedforpowerwheelchairnavigationandswitchoutput#2controllingsmartphonesingle-switchscanning.


• Transitioned speech recognition system toDragon NaturallySpeaking, setup customspeech commands for telephone control,andexpandedglobalcommandstosupportcompletehands-freecomputing.

• IntroducedNoHandComapponanHPiPAQdevicerunningWindowsMobile.


Accommodation(2013):TransitiontoSingleSwitchScanningPhase 1 – Performance evaluation. In January of2013thesubjectexperiencedaserioushealtheventwhich resulted in apermanent tracheotomy. This,combined with the advanced level of hisneuromusculardisease,eliminatedhisentireabilityto speak. Another computer access method wasneeded to replace functional goals previouslyaccomplished through speech recognition. Ad-vances inmobile technology switchaccesshad in-creased the subject’s mobile capabilities to fullyaccessing all features of an Android smartphone.This ClickToPhone system (developed in Ireland)wasunaffectedby the subject’shealthevent, andbecame the centerpiece of a radically changedperformance plan. Because of the extent ofquadriplegia, potentialmuscle sites for switch ac-cess were limited to up/downmovement of eye-brows(movingtogether),strongtwitchactionofleftpectoralmuscle,strongtwitchactionofleftcheek,andfaintmovementofrightthumb.Theleftpecto-ralmusclewasalreadydedicatedtocontrollingthesmartphone and navigating his power wheelchairvia a dual output EMG switch. And the eyebrows

Table42005FunctionalGoalsMatrixforTransitiontoContinuousSpeechRecognition

FunctionalGoals1.Placeandreceivephonecalls;


3.Manageinformationandemailbeyondhomeworkstation

EvaluationCriteria

(Sp)eed

Discretespeech,18wpm(ContinuousSpeech,pending)

Discretespeech,18wpm(Singleswitchscanning,pending)

(A)ccuracy Medium(High) Medium(High)(F)atigue Low Low Low(Medium)(L)oad Low Medium Medium(C)onsistency High High High(S)atisfaction High High Low(Medium)

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were committed to the operation of the powerwheelchair’semergencykillswitch.Thisleftthesub-ject’s left cheek as the most likely candidate forengaginganothertechnologyaccessmethod.Atele-phone/Skype accommodation was explored, inadditiontosmartphonecommunicationoptions.Phase2–Recognitionofobstaclesandopportuni-ties.Subjectcouldclearlybenefitfromseveralfea-ture enhancements to the ClickToPhone system,chiefamongwhichwasincreasingscanningratebe-yond333ms.Smartphonecouldinitiallybeprimaryaugmentative and alternative communicationdevice. Eyegaze technology and single switchscanning were the twomost likely candidates forreplacingspeechrecognition.Phase 3 – Assessment of solutions. The followingissueswereaddressed:

• Needed text-based Android App foraugmentative and alternative communica-tion.Alexicomapphadcapacitytosupportlarge, complex phrase collections withmulti-platformcompatibility.

• Smartphone SMS capabilities seemed to

provide satisfactory communication andstandard phone accommodation could bedroppedfromperformanceplan.

• Subject’s comfort level with single switchscanning became the driving factor inchoosingitovereyegazetechnologyasthesubject’s primary workstation accessmethod.Thoughithadnotseenasoftwareupdateinyears,Words+EZKeyswasstillthemost efficient and customizable productavailable for single switch scanning.Compatibility with Windows 7 was con-firmed.

• AbleNet’sSCATIRswitchwaschosenforEZKeys menu selections. Mounting schemeincluded placing the infrared sensor on anextendedmicrophone gooseneck, allowingit to be positioned about 1 cm from thesubject’s left cheek. Optimum switchplacement was aimed at maximumsensitivityforrapidtriggeringwithminimumfatigue.

• Switchunderworkstationdeskfortogglingthe speech recognition microphone wasretrofitted to toggle SCATIR switch on/off

Table52013FunctionalGoalsMatrixforSingleSwitchScanning

FunctionalGoals1.Placeandreceivephonecalls(Remove)


3.Manageinformation(andcommunicatebeyondhomeworkstation)

EvaluationCriteria

(Sp)eed

ContinuousSpeech,35wpm(Singleswitchscanning,pending)

Singleswitchscanning,5.7wpm

(A)ccuracy High Hig(F)atigue Low Low Medium(L)oad Low Medium Low(C)onsistency High High High(S)atisfaction High High High

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withwheelchair’spowerlegrests.Phase 4 – Technology intervention. The followingsolutionswereimplemented:

• Alexicom AAC app installed on Androidmobiledevicewithcloudbackupofcustomphrasecategories.

• IntroducedWords+EZKeyswithAbleNet’sSCATIRswitchandgooseneckmountaspri-maryworkstationaccessmethod.

• Adapted switch setup for wheelchair legreststotoggleSCATIRswitchon/off.

Phase5–Reviseplan.Changesresulting fromthistechnology accommodation are indicated withinparenthesesonTable5.Accommodation (2016): Combined Single SwitchScanningandEyegazePhase 1 – Performance evaluation. Evaluationcriteriashowedstrongefficacyforbothdesktopandmobile accommodations (1, 2).While 12.9words-per-minute is an outstanding text entry rate forsingle-switch scanning, it was still a productivity

limitationinviewofthesubject’shighdemandforwrittendocumentation.Eyegazewithswitchselec-tion could enable faster text entry. Likewise, anysystemenhancementsforimprovingtextentryrateon the mobile device was also considered. Thegrowing demand for creating and deliveringmultimedia presentations should be added toperformancegoals(3).Phase2–Recognitionofobstaclesandopportuni-ties.Twodisadvantagesofeyegazetechnologyare1)notintegratingwellwithmainstreamcomputingapplications; and 2) fatigue associated with eyestrain. Implementing eyegaze as a redundant,complementary inputmethodalongside thesingleswitchscanningmitigatedtheselimitations.Systemconfigurationneededtoallowthesubjecttoeasily,andindependently,switchbetweenthetwoaccessmethods.Clearestopportunityfor improvinginputrate on mobile device was to work with theClickToPhonedeveloper to increase themaximumscanningrate.Softwaresolutionsneededidentifiedformeetingnewperformanceexpectationofcreat-inganddeliveringpresentations.

Table62016FunctionalGoalsMatrixforCombinedSingleSwitchScanningandEyegaze

FunctionalGoals


2.Manageinformationandcommunicateonthego

3.Createanddelivermultimediapresentations

EvaluationCriteria

(Sp)eed

Singleswitchscanning,12.9wpm(+eyegaze,pending)

Singleswitchscanning,5.7wpm

(A)ccuracy High High (High)(F)atigue Low Medium (Low)(L)oad Medium Low (Low)(C)onsistency High High (High)(S)atisfaction High High (High)

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Phase 3 – Assessment of solutions. The followingissueswereaddressed:

• Subject’s workstation consisted of aMicrosoftSurfacePro3anddockingstationwithtwo19-inchdisplaysattached.Displaysmounted vertically to accommodate sub-ject’sinabilitytoturnhisheadsidetoside.Eyegazecontrolwastargetedonthetopdis-playtoaccommodatesubject’ssupinerest-ingposition.

• Optimumeyegazecalibrationstatisticsweresought through adjusting position ofcamera,tiltofdisplay,andangleofsubject’seyeglasses.

• Determinedoptimumtextentryratewouldbe reached through switch selectingeyegazetargets.

• ClickToPhonedeveloperagreedtoincreasemobiledevicescanningratefrom200msto100ms. Soft start feature would also beadded to enable better selection of firstmenuitemineachrow.

• In addition to Microsoft PowerPoint,Camtasiasoftwarewasidentifiedforcreat-ing multimedia presentations. CamtasiarecordingmodeiscompatiblewithWords+EZ Keys control. All In One Remote Server(Windows)andAllInOne(AOI)Remoteapp(Android)wereselectedtoallowsubjecttocontrol PowerPoint presentations on theSurface Pro 3 remotely from his Androidsmartphonewhenawayfromdockedwork-station.


• Introduced EyeTech TM5 eyegaze system.Mounted camera on top of lower display,witheyegazecontrolaimedattopdisplay.

• Implemented trial with ClickToPhonescanningspeedat100msandsoftstartfea-tureat125ms.

• Introduced Camtasia for multimediadevelopment, and All In One Remote andServer for independently conducting

presentations.


DiscussionThe six ATOP cycles outlined in this paper clearlyshowevolvingobstaclesandopportunitiesresultingfrom changes in technologies, user abilities, anduserexpectations.ItisinterestingtonotehowmanyaccommodationsrequiringanATsolution20yearsago now have the needed functionality built intomainstream technology. The fundamental assess-ment process remains the same, but todaymanytools are immediately available and bundled instandardoperatingsystems.Forexample,adjusta-ble keyboarding delays and sequencing; mousespeed, sensitivity, pointer size and shape; screenmagnification and text-to-speech; speech recogni-tion and universal switch access are among thestandard features of most mainstream technolo-gies.Itisimportanttoappreciatethatthefocusofeachtechnologyinterventionistomaximizeproductivity.Theevaluationcyclethereforewouldbebeneficialtoanycomputingtechnologyuser,withorwithoutadisability,wishingtomaximizetheirproductivity.For example, enormous productivity gains can berealized through combined keyboard/speechrecognition input. How this is implemented, how-ever,dependsonthefunctionalgoalsandabilitiesoftheuser.Theoverarchingprincipalshouldbetomaximize the user’s strengths and minimize theirweaknesses, and to focus productivity on inten-tionalgoals.Toillustratethisprinciple,onecanlookattheinitial(1989)FunctionalGoalsMatrix(showninTable1).Thesubject’sinitialperformanceplanincludedfourfunctional goals associated with his employmentexpectations. The subject’s text input rate isarguablythemostsignificantmeasureandwehaveextracted these data points to create Table 7. In

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Table7, changes in text entry rate canbe seen; aresult of buffering disease progression with AT.Major technology interventionsoccur in1993andagain in2013,bothofwhichwerenecessitatedbysignificant losses in the subject’s physical abilities.Betweenthesetwoturningpointswecanobserve20 years of increased productivity marked bynegligiblefatigueassociatedwithtextentry.With speech recognition technology, the subjectwasabletorealizesteadyincreasesinhistextentryrate, culminating at 35 words-per-minute viacontinuousspeechrecognition.Inotherwords,thenetresultwas improvedbecausetechnologygainssteadilyoutpacedthesubject’sdiseaseprogression.

MainstreamtechnologyandATadvanceintandem,butalwaysatdifferentratesofchange.Howthisim-pacts decisionmaking about technology interven-tionsismostevidentinthesubject’s1999and2005accommodations(seeTables3&4).Whilediscretespeech recognition continued to show strongefficacyandhighsatisfactionforthesubject,itwasbecominganobsoletetechnology.By1998,DragonDictate for Windows was no longer activelysupported by the developer. Advances in theWindows operating system posed a significantcompatibility threat to this discrete speechrecognition software thatwas no longer receivingupgrades.Furthermore, itwouldnotbeuntil2005thatcontinuousspeechrecognitioncouldofferthe

Table7TextEntryRates,1989–2016

InterventionRate

(wpm)Fatigue InputType

1989 Pre 20 Medium One-handedtyping

Post 20 Medium One-handedtyping

1993 Pre 9 High One-handedtyping

Post 18 Low Discretespeechrecognition

1999 Pre 18 Low Discretespeechrecognition

Post 18 Low Discretespeechrecognition

2005 Pre 18 Low Discretespeechrecognition

Post 35 Low Continuousspeechrecognition

2013 Pre 35 Low Continuousspeechrecognition

Post 12.9 Low Singleswitchscanning

2016 Pre 12.9 Low Singleswitchscanning

Post Pending Low Scanning/Eyegaze

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recognition accuracy and advanced customizationfeatures needed to accommodate the subject’scompromisedpulmonarycondition.Thesubject’s textentryratepeaked in2013at35wpm. As noted previously, it was at this juncturethat thesubjectexperiencedacatastrophichealthevent resulting in loss of speech due to atracheotomy. Fortunately, the text entry methodalready being exercised with the subject’s mobiledevicesofferedasmoothtransitiontoworkstationaccess via single switch scanning. Though thesubjectwasabletousesingleswitchscanningwithgoodefficacy,itsmaximumrateofinputaftertwoyearsonlyreached12.9wpm-a63%dropfromthatreached with continuous speech recognition.Despite this setback to textproduction, the singleswitchscanningimplementationofferedlowfatigueandeventuallyhighsatisfaction.Thefinalevaluationtodateoccurred in2016,andreflects a return to ATOP’s proactive interventionapproach. At this point, a combined scan-ning/eyegazeaccessmethodwasintroduced.Akeycomponenttothissystemwastheuserbeingableto readily and independently switch between thetwomodesofinput.Textentryspeedsforeyegazearetypicallyconstrainedbydwelltime(i.e.thetimerequiredtogazeatatargetbeforeitisselected).Forexample,a1seconddwelltimewouldresult inanupper limit typing speed of 12 wpm (Majaranta,MacKenzie,Aula,&Räihä,2006).Thus,becausethesubjecthadtheoptiontotriggereyegazeselectionswithhisswitchofchoice, itwashypothesizedthatthe reduced selection time (between 100ms and

200msperletter)wouldleadtoatypingspeedover20wpm.Itwasfurtherhypothesizedthatthesharedloadwithsingle-switchscanningwouldalsomitigateissues associated with eye strain and eyegazeinefficiencieswithmainstreamtechnologies.

OutcomesandBenefitsWhen we consider the outcomes and benefits ofcontinuous and rigorous technology interventionsthatareaimedatmaximizingproductivity,wemustunderstandthebenefitsofdiscoveredbestpractice.Best practice discovery is a user-centered processthatinvolvesatechnologyconfigurationthatisabletoadapttotheuserwhiletheuserisalsoadaptingto thesystem.Theaim isproductivity.Themeansaremany and varied. For example, the subject ofourstudybeganwithaccesstobothWindowsandApple workstations. Keyboard accommodationsweremadealongsideintegrationofspeechrecogni-tion. And later, single-switch scanning was com-bined with eyegaze control. These redundanciesillustratethebenefitofallowingbestpracticestobediscoveredbytheuser,insteadofbeingahypothe-sisoftheATpractitioner.Note,inadditiontodiscov-eryofbestpractices,havingredundanciesbuiltintothesystemoffersoff-loadinginresponsetofatigueand increased system reliability. Specifically, thestudy subject’suseof EMGswitch technology is agood example (see Tinkertron Dual EMG switchdescription, included in the section on 2005accommodations).ThesubjectdevelopedskillsetsforbothprimaryandsecondaryplacementsoftheEMGelectrode.Primaryplacementwasabove theleft pectoral muscle, which offered high accuracy

Table8Task/Load&ElectrodePlacement

TaskEMGElectrodeplacements

Primary Secondary

Powerwheelchairnavigation Heavy Light

Smartphonetextentry Light Heavy

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(trigger timing) and moderate fatigue (repetitivetriggering). Secondary placement was on the leftcheek,whichofferedlessaccuracyduetoinadvert-ent triggering. Virtually no fatigue was associatedwith cheek-muscle triggering. Using thesemodes,the discovered best practice for EMG controlwasgradually established and is conveyed in Table 8.While the primary placement is ideal for heavynavigationaluse,thesecondaryplacementstillpro-vides abackup in casesofmuscle strainor injury.When the subject was away from his computerworkstation, increased reliance of mobile devicetext entry could be accommodated through thesecondaryplacement. This built-in redundancy re-sults in healthier and more reliable use of thetechnology.Ideally, when there are multiple access methods,thereshouldbecustomizationoptionsthattheusercanmodifyindependently.Anexampleofthisissin-gleswitchscanningparameters(e.g.keyboardlay-outs,scanningandpauserates,scanningpatterns,etc.).Withinthisphilosophy,usertrainingincludesor even begins with accessing the system’scustomizationfeatures.Timely, user-driven adjustments can lead to out-comes that promote technology adoption. In ourcase study, keyboard and trackball usesupplemented speech recognition. As a result ofdisease progression, however, speech recognitiongradually replaced both for text entry andmousecontrol.Butthishappenednaturally,withtheuser’sabilitiesandpreferencesdrivingthechange.Resultsarependingwithregardtothesubject’scombinedscanning/eyegaze technologyaccommodation,buttheexpectedoutcomeshouldrevealwhenandforwhatpurposeseachmethodismostefficientforthesubject.Userself-determinationisanunderlyingprincipalofthiscyclicalevaluationprocess.Thisisnotonlytruephilosophically, but pragmatically: the efforts toprovideredundantaccessmethodscreateamecha-nism that facilitates self-determination. Thus, it isreasonabletoexpectmorepositiveoutcomestobe

derived fromtheenhancedself-determinationbe-ingexercised(Wehmeyer,2004).Efficacyof theATOPmodelshouldalsobeconsid-ered in termsof the culminating outcomesof thecycleovertime.Inthecasestudypresented,theselong-termbenefitsincluded:

1. Ausermindsetofcontinuousimprovement;2. Ahabitofproactivechange;and3. Acontinuumofoptimalproductivity.

Conclusion

Assistive technology can be life-changing technol-ogy.Thecasestudypresentedrepresentsoneofthemost challenging scenarios in the practice of ATassessment and intervention. Severe andprogressing limitations coupled with highperformanceexpectationsrequirethemostATcangive. Change, both positive and negative, is aparameterthattoucheseveryaspectoflife.Through this case study, the Assistive TechnologyOptimization Process showed itself to be theneeded scaffolding to track, plan, and integratechangingtechnologytomeetchangingexpectationsinthefaceofchangingcapabilities.AsnotedintheDiscussionsection,severaltrendscanbeobservedwithin the course of the study where technologybenefits outpaced disease progression. For thestudysubject,hisemployer,andthefieldofassistivetechnologythatissuccess!

DeclarationsThecontentissolelytheresponsibilityoftheauthoranddoesnotnecessarilyrepresenttheofficialviewsof ATIA. No financial disclosures and no non-financialdisclosureswerereportedbytheauthorofthispaper.

SpecialThankstoDr. Joseph Jersak, Carma Messerli, AbigailO’Sullivan,andDr.CherylShigakiforassistinginthepreparationofthismanuscript.

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References

Federici,S.,Meloni,F.,&Borsci,S.(2016).The

abandonmentofassistivetechnologyinItaly:asurveyofNationalHealthServiceusers.EurJPhysRehabilMed,52(4),516-526.

Jenko,M.,Matjacic,Z.,Vidmar,G.,Bester,J.,

Pogacnikb,M.,&Zupan,A.(2010).Amethodforselectionofappropriateassistivetechnologyforcomputeraccess.[ComparativeStudyResearchSupport,Non-U.S.Gov't].IntJRehabilRes,33(4),298-305.doi:10.1097/MRR.0b013e3283375e35

Majaranta,P.,MacKenzie,I.S.,Aula,A.,&Räihä,K.

J.(2006).Effectsoffeedbackanddwelltimeoneyetypingspeedandaccuracy.UniversalAccessintheInformationSociety,5(2),199-208.

Mumford,L.,Lam,R.,Wright,V.,&Chau,T.(2014).

Anaccesstechnologydeliveryprotocolforchildrenwithsevereandmultipledisabilities:acasedemonstration.DevNeurorehabil,17(4),232-242.doi:10.3109/17518423.2013.776125

Phillips,B.,&Zhao,H.(1993).Predictorsof

assistivetechnologyabandonment.[ResearchSupport,U.S.Gov't,Non-P.H.S.].AssistTechnol,5(1),36-45.doi:10.1080/10400435.1993.10132205

Steel,E.J.,Gelderblom,G.J.,&deWitte,L.P.

(2012).TheroleoftheInternationalClassificationofFunctioning,Disability,andHealthandqualitycriteriaforimprovingassistivetechnologyservicedeliveryinEurope.[ComparativeStudyReview].AmJPhysMedRehabil,91(13Suppl1),S55-61.doi:10.1097/PHM.0b013e31823d4ee6

Wehmeyer,M.L.(2004).Self-determinationand

theempowermentofpeoplewithdisabilities.AmericanRehabilitation,28(1),22-29.

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ImpactofSelf-RegulatedStrategyInstructionIntegratedwithSOLO®LiteracySuite

KarenErickson,PhD

LoriGeist,PhDPenelopeHatch,PhD

CenterforLiteracyandDisabilityStudies,UniversityofNorthCarolinaatChapelHill

AbstractWritingisacomplexprocesswithmultiplecompo-nents that require concurrent consideration. Self-regulated strategy development (SRSD) is anempirically supported approach for teaching stu-dents strategies for planning, generating and/orrevisingtheirwriting.Thecurrentstudyinvestigatedwhether SRSD integrated with the use of SOLO®LiteracySuitewouldleadtogainsinwritingskillsforstudents ingrades3and4.Paired samples t-testswereconductedtodetermineiftherewasasignifi-cantincreaseinstudentperformanceonsubtestsoftheTestofWrittenLanguage–3(TOWL;Hammill&Larsen, 1996). On average, students performedsignificantlybetteratposttestonapaper-penciltestwhen theyhad access to the SOLO® Literacy Suiteduringinstructionthanwhentheydidnot.Keywords: self-regulated reading strategy,writingskills,SOLO®LiteracySuite

IntroductionWritingisacomplexprocessthatrequiresattentionto the mechanics of transcription as well as thecomposition, organization, and presentation of

ideas(DeSmedt&VanKeer,2014;Harris,Graham,Mason, & Saddler, 2002).Writers must attend tospelling, grammar, and punctuation whilesimultaneouslyconsideringthecontent,form,pur-pose, and audience for which they are writing(Graham, McKeown, Kiuhara, & Harris, 2012).Skilledwritersaccomplishthesetasksbytakingtimeto plan, compose, and revise theirwork, applyingstrategies to manage these steps as they write(Baker, Gersten, & Graham, 2003; Santangelo,Harris&Graham,2008). They also engage in self-regulation to monitor and direct their individualefforts while composing (Lane, Harris, Graham,Weisenbach, Brindle, & Morphy, 2008; Mason,Harris,&Graham,2002).Studentswhohavedifficultywriting,includingthosewith disabilities, often lack knowledge about thecharacteristicsandprocessesrequiredforsuccess-fulwriting(MacArthur,2000;Zumbrunn&Bruning,2012).Thesestrugglingwritersfrequentlyapproachwriting tasks as knowledge telling exercises asopposed to composition processes (McCutchen,2000; Santangelo et al., 2008; Troia & Graham,2002;Zumbrunn&Bruning,2012).Ratherthantak-ing time to plan, struggling writers write downeverything they know about a topic using few

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strategies (Baker et al., 2003; Harris & Graham,2013;Santangeloetal.,2008).Additionaldifficultieswithmechanics often place a heavy focus on thetranscriptionprocessortheactofputtingwordsonthepage.Thiscombinationofdifficultiestaxesthewriter’s working memory capacity and compro-misesawriter’sabilitytoattendtothehigherorderskills used for quality composition and revision(MacArthur,2000).Thetypicalresultiswritingthatislowerinbothqualityandquantitythanthatpro-duced by students who do not struggle to write(Gersten & Baker, 2001; MacArthur, 2000;Zumbrunn&Bruning,2013).As they progress through elementary school,struggling writers, who may have initially beenenthusiasticaboutwriting,begin todevelopnega-tive attitudes toward writing (Harris & Graham,2013; Mason et al., 2002). Their difficulties withwritingcanleadtoreciprocalrelationshipsbetweenrepeatedacademicfailures,apoorself-imageasawriter, low motivation, limited task engagementand persistence, devaluation of learning, and lowproductivity(Harris&Graham,2013;Masonetal.,2002; Sturm & Rankin-Erickson, 2002). Adding totheseproblems,studentswhostrugglewithwritinghaveatendencytooverestimatetheirabilitiesandapproachwritingtaskswithunrealisticexpectations(Harris&Graham,2013;Harrisetal.,2003;Masonet al., 2002). Students who face these challengesneedexplicitinstructionthataddressesthewritingprocess through skill development, strategies forcomposition,andapositiveviewof themselvesaswriters:self-regulatedstrategydevelopmentisoneevidence-based approach that meets thisrecommendation (Harris&Graham,2013;Mason,Harris,&Graham,2011).

Self-RegulatedStrategyDevelopmentGraham, Harris, and their colleagues begandeveloping and studying self-regulated strategydevelopment (SRSD)more than20 years ago. TheaimofSRSDistoteachstudentsstrategiesforplan-ningand/orrevisingtheircompositions(DeLaPaz&Graham, 1997; Graham, Gillespie, & McKeown,

2013).Theapproachhasbeenempiricallyvalidatedin more than 25 studies involving a variety ofindividual,smallgroup,andclassroomsettings(e.g.,Graham, 2006; Graham et al., 2012; Harris &Graham,2013;Harriset.al,2003;Masonetal.2002;Santangelo, et al., 2008; Troia & Graham, 2002).Recentmeta-analyses (Graham, 2006; Graham, etal.,2012;Graham&Perin,2007)foundthatSRSDisone of the most effective approaches to writinginstruction. Of the 20 studies related to strategyinstructionthatGrahametal.(2012)reviewed,the14SRSDstudieshadlargeraverageweightedeffectsizes (1.17) than the 6 non-SRSD studies (0.59).GrahamandPerin(2007)reportedthelargestaver-age weighted effect size for SRSD relative to allother writing interventions included in theirinvestigation.SRSD has been used in multiple academic areas.Whenappliedtowriting,SRSD is intendedtohelpstudents becomemore fluent, independent, goal-oriented,self-regulated,andreflectivewriters.Theunderlying premise of SRSD is that students whostruggle to write need an integrated instructionalapproach that explicitly targets their affective,behavioral,andcognitivestrengthsandweaknesses(Harris & Graham, 2013; Harris et al., 2003). ThethreeprimarygoalsofSRSDaretohelpstudentsde-velopknowledgeaboutthewritingprocessthroughtheuseof strategies, touse self-regulationproce-dures tomonitor andmanagewriting, and to de-veloppositiveattitudesaboutwritingandtheirabil-ity towrite (Harris &Graham, 2013; Harris et al.,2003;Troia&Graham,2002).Thesegoalsareimportantgiventhatmanystudentsin the US, both with and without diagnoseddisabilities, strugglewithwriting.According tona-tionalreports,approximately15%of4thgradestu-dents (National Center for Education Statistics,2003,2012a),20%of8thgradestudents,and21%of12thgradestudentsareunabletoproducewritingat a basic level (National Center for EducationalStatistics,2012b).Moreover,74%of8thgradestu-dents and 73% of 12th grade students failed todemonstrateproficiencyonnationalassessmentsof

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writing (National Center for Educational Statistics,2012).Giventhesedeficits,itisalarmingtofindthatteachersoftendedicateonly15minutesperdaytoteaching writing and infrequently use evidence-basedwritinginstructionalstrategieswhentheydoteachwriting (Gilbert&Graham,2010).Given theflexibilityofSRSDtobemodifiedtomeettheneedsofbothstudentsandteachers,itispossibletointe-grateitwithotherliteracyinstructionalapproaches,including less explicit process approaches such asWriter’sWorkshop(Graham&Harris,2003;Graham&Sandmel,2011).Theexplicitinstructioninspecificself-regulation strategies and instructional compo-nentsofSRSDcansupport theneedsof individualstudentswhilebeingintegratedintotheframeworkofthewholeclass(Harrisetal.,2003).

RemovingBarriersThedifficultiesstrugglingwriterswithandwithoutdisabilities often have with the mechanics oftranscriptiontypicallyresultintoomuchconcentra-tion on spelling, handwriting, capitalization, andpunctuation, as well as reduced attention toplanning and evaluating the overall quality of thewriting(Graham,1999).Revisionsareoftenfocusedonerrorcorrectionratherthanqualitativeimprove-ments,andstudentssometimesinadvertentlypro-duceadditionalmechanical errorsduring the revi-sionprocess(MacArthur,2000).Theseissuesresultin mechanical barriers that make writing morechallenging.Removingthemechanicalbarriersstrugglingwritersfacerelatedtospelling,grammar,punctuationandrate(Santangeloetal.,2008)isjustonecomponentofimprovingoutcomes(DeLaPaz&Graham,1997).For example, to eliminate barriers, De La Paz andGraham (1997) combined dictation with SRSDinstructionfocusedonplanningto improveresultsformiddlegradestudentswithlearningdisabilities.DeLaPazandGrahamassignedthestudentstofourgroups. Two received SRSD for planning and twolearned about the characteristics of good essayswithopportunitiestoreadandrevisemodelessaysandwriteandsharetheirworkwithpeers.Halfof

the students in each instructional approachwrotetheirworkwhiletheotherhalfofthestudentsdic-tated, thus eliminating the challenge of transcrip-tion.Theresultsofthestudyindicatedthatsimplyremovingthemechanicalbarriersdidnot result inthehighestqualitywriting.Instead,themostcom-pleteandhighestqualitywritingcamefromthestu-dentswhohadthebenefitofusingdictationtore-duce mechanical barriers combined with SRSDinstruction inadvanceplanning.Thecurrentstudybuilds on this finding by combining SRSD withassistive technology that is designed to reducemechanicalbarriers.OutcomesandBenefits:ComputerTechnology

SupportComputerscanprovideimportantsupportstowrit-ers (Cutler & Graham, 2008) and reduce manymechanicalbarriersthatstrugglingwritersface(DeSmedt&VanKeer,2014;Lewis,1998;MacArthur,2000). Students whose teachers regularly suggesttheuseofcomputersfordraftingandrevisingworkscorehigheronassessmentsofwritingthanthosewith teachers who suggest the use of computersless frequently or not at all (National Center forEducation Statistics, 2012); yet reported use ofcomputersinwritinginstructionremainslow,withone random sample of 178 primary educatorsrevealingthat42%neverusedcomputersinwritinginstruction(Cutler&Graham,2008).Word processing is a specific example of a use ofcomputers that removes handwriting barriers andresults in positive effects on theoverall quality ofwriting(DeSmedt&VanKeer,2014;Grahametal.,2012;Morphy&Graham,2012).However,thereisvariabilityintheeffectsofwordprocessingaloneasa support for writing (Graham & Perin, 2007;Morphy&Graham,2012).GrahamandPerin(2007)reported that the variability is not related to thespecific interventions, characteristics of the stu-dents, length of the intervention, or other factorsthatwouldtypicallyexplainvariationsintheimpactof educational interventions. They concluded thatwhile word processors have an overall positive

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effect on writing, the impact of word processorsalonevariesbasedonfactorsyettobedetermined.Whiletypingremovesoneobvioussetofmechani-cal barriers, software programs can include sup-portsgeared specifically toward removingbarriersassociated with planning, outlining, and revisionprocesses(Morphy&Graham,2012).Forexample,SturmandRankin-Erickson(2002) investigatedtheeffectofconceptmappingontheexpositorywritingskills of 20 middle school students with learningdisabilities. All students received SRSD instructionforconceptmapping,andtheauthorscomparedtheeffects of drawingmaps by hand to using a com-puter software program. Both conditions yieldedsignificantincreasesinquantityandqualityofwrit-ingaswellascarry-overeffectstowritingwithouttheuseofaconceptmap.Animportantadditionalfinding indicated that students had a significantlymorepositiveattitudetowardwritingwhencreat-ingconceptmapsonthecomputerthanwhenhand-drawingornotusingconceptmaps.Thecombina-tionoftechnologywithSRSDresultedinbothbetterwritingandmorepositiveattitudestowardthepro-cess.Spell checkers may improve the revision process,particularly with respect to the identification andcorrectionofminorerrors,butthereisapaucityofresearchprovidingclearguidanceonuse(Graham&Perin, 2007; Morphy & Graham, 2012). Further-more, spell checkershave limitationswith respecttotargetvocabularynotbeingpresentedonlistsofsuggestions to students, and misspellings of in-tendedwordsnotreliablydetected,particularlyforhomonymsortypingerrorsthatresultinrealwords(MacArthur, 2000). Limitations aside, some stu-dents can improve their use of spell checkers bylearningstrategiestogeneratethetargetwordwithphoneticspelling,andproofreadingtheirwritingtosee if the spell checker missed any errors(McNaughton, Hughes, & Ofiesh, 1997). For stu-dentswith severe spellingproblems,wordpredic-tionsoftwaremayprovidemoresupportthanspellcheckers by improving spelling accuracy andincreasing motivation, particularly when the

availablevocabularyismatchedtothewritingtask(MacArthur, 2000). Similarly, speech synthesiscapabilities that translate text into computerizedspeech can provide students with supports forlisteningtohowtheirwritingsoundstoguiderevi-sionandeditingwork,butsufficientresearchislack-ingtounderstandthefullbenefitsofthistechnology(Graham&Perin,2007).

TargetAudienceandRelevanceWritingisacomplexprocessthatcanposemultiplechallenges for strugglingwriters across thegrades(Harrisetal.,2003;MacArthur,2000;Zumbrunn&Bruning,2012). Interventions intended to improvewritingcanfocusonsinglecomponentsofthecom-plexprocesssuchasusingconceptmappingduringplanning (Sturm & Rankin-Erickson, 2002) ormultiple components simultaneously such aswrit-ingastoryoranexpositoryessay(Graham&Harris,2005). When instruction involves SRSD, theseinterventionsaremoresuccessful(Graham&Perin,2007),andcombining theSRSD interventionswithtechnology (Cutler & Graham, 2008) or otherapproachesintendedtoremovebarriers(DeLaPaz&Graham,1997)improvesstudentoutcomes.Thecurrent study contributes to this growing area byinvestigatingthecombinedbenefitsofSRSDandtheSOLO® Literacy Suite (Don Johnston Inc., 2007), asuite of literacy software tools including text-to-speech,graphicorganizer,andwordpredictionpro-grams, with struggling writers in grades 3 and 4.Ultimately,thetargetaudienceincludeseducators,clinicians,andfamiliesstrivingtosupportstudentsingrades3-12whoarestrugglingorotherwiseneedtoimprovetheirabilitytowriteparagraphsand/ornarrative texts. The primary research questionaddressedwas,Does SRSD integrated with use ofSOLO®LiteracySuiteleadtogainsinwritingskillsforstudentsingrades3and4?

MethodsFourteachers,twoeachingrades3and4,werere-cruitedforparticipationintheproject.Onceteachervolunteersweresecured,allofthestudentsintheir

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classes were recruited to participate in theinvestigation.Theoriginalplanwastoimproveourunderstandingofthewaysteachersusedthetoolsin SOLO® to create assignments to support theimplementation of the SRSD with their students.Theoriginaldesignwasaquasi-experimentalgroupdesign comparing researcher-made SOLO® assign-ments that integrated the tools in SOLO andteacher-madeSOLO®assignmentsthatmayormaynothaveintegratedthetools.Assuch,oneteacherat each grade level was randomly assigned to acondition that would provide researcher createdassignments in the SOLO® software. The otherteachers,oneateachgradelevel,wereassignedtoaconditionthatrequiredtheteachertocreatetheassignments.Duringthefirstweekofthestudytheteachers in the SOLO® group with researchercreated assignments shared the assignmentswiththeotherteachers.Thiswasnotpartoftheresearchplan,buttheteamdidnotlearnaboutthesharinguntil the end of the second week when anotherroundofready-madeassignmentshadbeenshared.Asaresult, thetwogroupsweremerged intoone

and are reported here as a single-group, pre-experimental,pretest-posttestdesign investigatingwhether or not SOLO® with ready-madeassignments created by the research team to thespecificationsoftheclassroomteachersledtogainsinwritingperformanceforstudentsingrades3and4.TeacherTrainingThe teachers all received training during a 90-minuteafter-schoolsessiononSRSDandthevariouswritingstrategiesthatcanbetaughtusingtheSRSDapproach. Each grade level then selected thespecificstrategytheywantedtoaddressintheSRSDinstructionwiththeirstudents.ThetwoteachersateachgradeleveltaughtthesamestrategyusingtheSOLO® assignments createdby the research team.ThetwodifferentstrategiesaredescribedinFigure1.The four teachers had an average of 12 years ofteachingexperience(range=3-30years).Allofthe

Figure1.DescriptionofWritingStrategiesAddressedatEachGradeLevel

3rdGrade:SummaryWritingStrategy1.Readthetext.2.Identifyandwritedownthemainidea.3.Identifyandwritedowntheimportantthingsaboutthemainidea.4.Rereadthetexttomakesurealloftheimportantideasareinthelist.5.Writeatopicsentence.6.Numbertheimportantideasusing1forthemostimportant.7.Turnthetopicsentenceandlistofimportantideasintoaparagraph.8.Rereadthesummaryparagraphtomakesureitmakessense.9.Askyourself,“HaveIleftanythingout?”4thGrade:NarrativeWritingStrategySSCARE

SituationSettingCharactersActionReactionEnding

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teachers had a master’s degree. None of theteachers identified themselves as “verycomfortable”withusingcomputersintheirteachingprior to the investigation. One teacher indicatedthatshewas“veryuncomfortable”usingcomputersforpersonaluseorwithherstudents.Theremainingthreeteachersreportedthattheywerecomfortableusingcomputersforpersonaluseandwiththeirstu-dents.Teachers also participated in a second 90-minutetraining focused on SOLO®. A member of theresearchteam,whoisanexperiencedschool-basedassistivetechnologyserviceproviderandwhoholdsprofessional certification in assistive technology,conductedthetrainingintheschool’scomputerlab.Duringthe6weeksoftheintervention,membersoftheresearchteammetweeklywiththeteachers(inthefirsttwoweeksitwaswithonlyoneteacherateachgradelevel)tounderstandhowtheywantedtouse SOLO® and create necessary assignments. Theresearchers then managed the distribution of allSOLO® assignments to the 26 computers in theschool’scomputerlabandthe28computersonthelaptop cart for the teachers to usewith their stu-dents.ThisresearchwasconductedusingaversionofSOLO®thatdidnotsupportnetworkdistributionofassignmentsorsharingofstudentfiles.ParticipantsAllstudentsintheclassroomsofthefourteacherswererecruitedforparticipationregardlessofwrit-ing ability, English language status, or disability. Atotal of 40 children (22 girls) participated in thestudy.Nineteenof the childrenwere in3rd gradeandtheremaining21werein4thgrade.Fourofthechildrenhadidentifieddisabilities,ninewereidenti-fiedasgifted,andthirteenreceivedfreeorreducedpricelunch.Thirtyofthechildrenwerewhite,ninewereAfricanAmerican,andonewasAsian.ProceduresThe entire investigation lasted ten weeks. Duringweeks1and2,childrenwhowereparticipating in

the research completed pretests and teachersparticipatedinthetrainingsessions.Duringweeks3through8,teacherscompletedeighteen45-minuteSRSD lessonswith all of the children in their classwhether or not they were participating in theresearch(seeAppendixAforexamplelessonplansasprovided for teachers).Duringweeks9and10,children who were participating in the researchcompletedposttests.TheTestofWrittenLanguage-3(TOWL;Hammill&Larsen,1996)FormAwasadministeredtoallpartici-pants at pretest and Form Bwas administered atposttest. This assessment is a pencil and paperassessment,andallstudentscompletedtheassess-mentwithoutaccesstoacomputerorthekindsofsoftwaresupportsfoundintheSOLO®LiteracySuite.While some students may have benefited fromaccesstoaccommodationswhiletakingtheTOWL,noaccommodationsor supportswereprovidedatpretest or posttest for any of the students. Theassessmentswereadministeredtosmallgroupsofstudentsbymembersoftheresearchteam.The two forms of the TOWL are reported to beequivalent(Hammill&Larsen,1996).Thedifferenceinmeanscoresacrossthetwoformswaslessthan0.5ofarawscorepointacrossthetwoformswhentheywereadministeredinonetestingsession.Thecorrelation coefficients across the two formswithimmediate administration exceeded .80. Asreported in the TOWLmanual (Hammill& Larsen,1996) test-retest reliability for the two forms alsoresulted in coefficients exceeding .80 for theContrived Writing Composite Score (r = .88), theSpontaneousWritingCompositeScore(r=.86),andtheOverallWritingScore(r=.89).TheSOLO®LiteracySuiteThere are four separate software applications in-cluded in the SOLO® Literacy Suite. They are inte-grated in SOLO® to address the barriers andchallenges faced by developing and strugglingwriters. For example, the first of the fourapplications is Draft:Builder®. This application

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supportsoutlining,note-taking,anddraftwriting.Ithasthepotentialtobenefitstrugglingwriterswhorarely take the time to plan before writing downeverything they know about a topic (Baker et al.,2003; Harris & Graham, 2013; Santangelo et al.,2008). Another application is Co:Writer®, whichoffers word prediction that supports spelling ofindividual words and the construction ofgrammatically correct sentences. This wordpredictionsoftwarehasthepotentialtoremovethemechanical barriers strugglingwriters face relatedto spellingandgrammar (Santangeloetal.,2008).Write:OutLoud® the talking word processorincluded in the SOLO® Literacy Suite, has a spell-checkerandeasilyaccessiblemenustochangefontsize, foreground and background colors, and thesynthesized voice that is used. This software hasfeaturesthatmakeitpotentiallyusefulasstudentswork to identify and correctminor errors in theirwriting(Graham&Perin,2007;Morphy&Graham,2012). Finally, the suite includes an applicationcalledRead:OutLoud,whichisatextreader.Thereareseveralothersoftwarepackagesthatin-cludemanyofthefeaturesofferedbySOLO®;how-ever,thefactthatSOLO®supportedwhole-classuseand the type of ready-made assignments theteachers used to implement SRSDmade it a goodchoiceforthisproject.TheInterventionAllfourteacherswereprovidedwithasequenceof18lessonsthatoutlinedtheimplementationofthewriting strategy they were implementing at theirgrade level. The 18 lessons did not provide infor-mationregardingtheimplementationofSOLO®,buttheydidprovideteacherswithaframeworktoguidetheir implementation of SRSD. The research teamprovided the lesson sequence in the interest ofmaximizing the fidelity of implementation of theSRSD approach while studying the impact of theadditionofSOLO®.SRSD Instruction. The six stages of the SRSDinstructionwerebuiltintothelessons.Thefirststep

emphasized building background knowledge andteachingpre-skillsneededforlearningandusingthewritingstrategyateachgrade level. Inthecaseofthecurrentstudy,lessonsfocusedonbuildingback-ground taught vocabulary specific to the strategy(e.g., topic sentence, topic, main idea) and skillsembeddedinthestrategy(e.g.,writingatopicsen-tence,determiningthemainidea).Thesecondstephelped students learn self-statements intended toregulatestrategyuse,thewritingtask,orinterferingbehaviors. Self-statements supported problemdefinition(e.g.,“WhatdoIhavetodohere?”),focusand attention (e.g., “I need to concentrate.”),encouraged self-evaluation and error correction(e.g.,“HaveIusedallmyparts?”),supportedcopingandself-control(e.g.,“Icandothis.Slowdown.”),andguidedself-reinforcement(e.g.,“Ilikemyend-ing.”).Self-statementsalsoincludedstatementsre-latedtoastepinthestrategy(e.g.,“Ineedtowritedownmystrategyreminder.”).The third step in the18-lesson sequence requireddiscussionof the strategy.Asdetailed in Figure1,this step required discussing the summarywritingstrategy inboththirdgradeclassesandthenarra-tive writing strategy in both fourth grade class-rooms.Theteacherexplainedthenewstrategyandeachstep.Theteacheralsodefinedthepurposeofthestrategy,thebenefitsofitsuse,aswellashowand when to use it. Discussion also examinedcurrentwritingperformanceandstrategiesusedtoaccomplishspecificwritingtasks.Thesediscussionsserved to encourage students tomake a commit-ment to learning the strategy and working as acollaborativepartnerinaccomplishingtheirgoal.The next step in the lessons required teachers tomodel the strategy and appropriate self-statements.Themodelsteachersprovidedshowedthe students how to use self-instruction thatincluded defining the problem, planning, applyingthe strategy, evaluating and correcting errors asneeded.Afterbuildingbackground,discussing,andmodelingthestrategy,teacherssupportedstudentsin memorizing the strategy itself using themnemonicasasupport.Finally,thelessonsguided

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teachers in supporting students in applying thestrategyuntilstudentscouldapplyitindependentlyintheirownwriting.IntegratingSOLO®.Membersoftheresearchteammet with teachers on a weekly basis, after theteachers had a chance to review the lessons anddeterminewhatmaterials theywould use. Duringthese meetings, teachers told researchers whatthey wanted to accomplish with SOLO®. Forexample,athirdgradeteacherwantedstudentstobe able to use Write:Outloud, the talking wordprocessorcomponentofSOLO®,tosupportstudentsin reading a short text they were going tosummarize as a group. A fourth grade teacherwanted students to use Co:Writer, the wordprediction component of SOLO®, to support herstudents’selectionof“big”wordsthat“theyusuallydon’t try to write because they can’t spell.” Tosupportthethirdgradeteacher,theresearchteamtypedthetextprovidedbytheteacherandloadeditontoall of the computers in the labandon thelaptopcart.Tosupportthefourthgradeteacher,theresearch team created a Topic Dictionary inCo:Writerthatincludedallofthewordswiththreeormoresyllablesinthetexttheywerereadingandchanged the user dictionary from beginner toadvanced toensure that the“big”words studentsweretryingtowritewouldbeavailable.Inthisway,teachers had access to the ready-made supportstheywantedinSOLO®withouthavingtocreatethesupportsthemselves.Fidelity.Members of the research teamobservedteachers implementing the SRSD to ensure thatteacherswereimplementingthelessonsinthewaythey were designed. The emphasis was on theimplementation of the steps of effective SRSD asoutlined in the lessonplans and consistent use ofthe strategy selected for each grade level.Observation forms were created from the lessonplans and each step was marked as teacherscompleted it.Across100%of theobservations (atleast three per classroom conducted by twoseparatemembersoftheresearchteam),teachersimplemented the targeted steps of SRSD and

focusedonthestrategyselectedforthegradelevelwith100%fidelity.

ResultsApairedsamplest-testwasconductedtodetermineif there was a significant increase in studentperformanceontheTotalWritingscoreoftheTOWLfrompretesttoposttest.Onaverage,studentsper-formed significantly better on the posttest (M =66.75,SE=3.096),thanthepretest(M=58.95SE=3.03,t(39)=-4.137,p<.001,r=.55).Thisincreaseinrawscorecorrespondswithanincreaseinoverallpercentilerankfromthe12thpercentiletothe23rdpercentileandanincreaseinquotientfrom82to89.Importantly,thesegainsonapaperandpenciltestofwritingwerefoundacrossthetwosubtestsoftheTOWL, the Contrived and Spontaneous subtests.Paired samples t-tests were also run on theseindividual subtests. On average, studentsperformed significantly better on the posttestadministrationoftheContrivedsubtest(M=39.43SE = 2.05) than the pretest (M= 36.00SE = 1.77,t(39)=-3.425,p<.002,r=.48).Thisincreaseinrawscoreonthesubtests thatcomprise theContrivedsubtest corresponds with an increase in overallpercentilerankfromthe10thpercentiletothe16thpercentileandanincreaseinquotientfrom81to85.Similarly, on average, students performed signifi-cantlybetterontheposttestadministrationoftheSpontaneoussubtest(M=27.33,SE=1.31)thanthepretest(M=22.95,SE=1.62,t(39)=-4.375,p=.002,r = .57). This increase in raw score on theSpontaneoussubtestcorrespondswithanincreaseinoverallpercentilerankfromthe13thpercentileto the35thpercentileandan increase inquotientfrom83to94.Descriptive statistics from the four students withidentifieddisabilitiessuggeststhattheybenefittedfrom the use of SOLO® with SRSD in a way thatmirroredthewholegroup.Forexample,themeanTotalWritingrawscoreforthesestudentsincreasedfrom63.50(SD=17.098)atpretestto72.75(SD=21.469) at posttest. Their scores on theContrivedsubtest increased from 39.00 (SD = 13.342) at

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pretestto42.75(SD=13.226)atposttest,andtheirscoresontheSpontaneoussubtestincreasedfrom24.50(SD=4.123)atpretestto30.00(SD=8.287)at posttest. Each of the four studentsmade gainsfrompretest to posttest on the TotalWriting rawscore.Furthermore,theincreaseinrawscoreonthesubtests that comprise the Contrived subtestcorrespondswith an increase in overall percentilerank from the 16th to the 25th percentile and anincrease in quotient from 85 to 90. On theSpontaneoussubtest,theincreaseinrawscoresoncorrespondswith an increase in overall percentilerank from the 20th to the 50th percentile and anincreaseinquotientfrom88to100.

DiscussionTheevidencebasesupportingtheuseofSRSDwithpopulations of students with and withoutdisabilitiesisquitestrong,buttheevidencebaseforthe use of software to support effective writinginstruction remains limited. This study does notprovide definitive evidence that using SOLO®improvedoutcomesstudentswouldhaveachievedafter6weeksof instructionwithSRSD,butitdoessuggest that SRSD resulted in positive writingoutcomes even when teachers took the time toteach students to use software while they werelearning strategies. Equally important, studentsmade significant improvements on a standardizedpaper and pencil writing assessment even whentheyusedacomputertowriteduringthesixweeksofinstruction.With the rapidly expanding availability of durable,portableandinexpensivemobileplatforms,nowisanoptimaltimetoleveragetheuseofsoftwaretomaximize the effectiveness of writing instruction.Giventhereportedunderutilizationofcomputersinwriting instruction (Cutler & Graham, 2008), it isrelevant to note that the teachers involved in thecurrentstudydidnothaveadvancedskills inusingtechnology prior to implementing SOLO® in theclassroom. None of the participating teachersreportedbeing“verycomfortable”usingtechnologywith their students prior to the investigation, yet

witha90-minuteoverviewtrainingandoccasionalconsultation with the research team, they weresuccessful in using computers as part of theireverydaywritinginstruction.The findings of this study do not provideinformation regarding which applications orfeatures in the SOLO® Literacy Suite were mostimportant to the teachers and students in thecurrent investigation. It ispossible thatadifferentcombination of applications ormore emphasis onparticular features would have resulted in evengreater gains for theparticipants. Future researchshould employ designs that control for the use ofeachofthesoftwareapplicationsandmoredirectlymeasuretheirindependentandcollectiveimpact.Thisstudyaddstothe literaturebydemonstratingthat sixweeksof instructioncombiningSRSDwiththe SOLO® Literacy Suite and custom-madeassignments is associated with significant growthacrossthecontrived(mechanical)aspectsofwritingaswell as those required for spontaneouswriting(organization, composition and presentation ofideas) when students do not have access to thecomputer.Althoughthecurrentstudyislimitedtoasingle-group, pre-experimental, pretest-posttestdesign, and does not allow for causal claimsregardingtheaddedbenefitsofthetechnologywithSRSD, the outcomes data support that studentsdemonstrated improvedwritingona standardizedtestofwritingasaresultofinstructionfocusedonasingle strategy, delivered through an instructionalapproachbuiltonSRSD that integrated theuseoftheSOLO®LiteracySuite.

DeclarationsThis content is solely the responsibility of theauthors and does not necessarily represent theofficial views of ATIA. The authors disclosedfinancialrelationshipswiththeNationalCenterforTechnology Innovation, Technology in the WorksCompetition, and Don Johnston, Inc. No non-financialdisclosureswerereportedby theauthorsofthispaper.

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AuthorNoteAllauthorsarefacultyattheCenterforLiteracyandDisability Studies, University of North Carolina atChapelHill.Thepresentpublicationwasdevelopedin part under grant from the National Center forTechnology Innovations, Technology in theWorksCompetitionwithmatchingfundsprovidedbyDonJohnston,Inc.

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65-79.Lane,K.,Harris,K.,Graham,S.,Weisenbach,J.,

Brindle,M.,&Morphy,P.(2008).Theeffectsofself-regulatedstrategydevelopmentonthewritingperformanceofsecond-gradestudentswithbehavioralandwritingdifficulties.TheJournalofSpecialEducation,41,234-253.

MacArthur,C.(2000).Newtoolsforwriting:

Assistivetechnologyforstudentswithwritingdifficulties.TopicsinLanguageDisorders,20,85-100.

Mason,L.,Harris,K.,&Graham,S.(2002).Every

childhasastorytotell:Self-regulatedstrategydevelopmentforstorywriting.EducationandTreatmentofChildren,25,496-506.

Mason,L.,Harris,K.,&Graham,S.(2011).Self-

regulatedstrategydevelopmentforstudentswithwritingdifficulties.TheoryIntoPractice,50,20-27.

McCutchen,D.(2000).Knowledgeacquisition,

processingefficiency,andworkingmemory:Implicationsforatheoryofwriting.EducationalPsychologist,35,13-23.

McNaughton,D.,Hughes,C.,&Ofiesh,N.

(1997).Proofreadingforstudentswithlearningdisabilities:Integratingcomputeruseandstrategyuse.LearningDisabilitiesResearchandPractice,12,16-28.

Morphy,P.,&Graham,S.(2012).Word

processingprogramsandweakerwriters/readers:Ameta-analysisofresearchfindings.ReadingandWriting:AnInterdisciplinaryJournal,25,641-678.

NationalCenterforEducationStatistics.(2003).

TheNation’sreportcard:Writing2002

(NCES2003–529).Washington,D.C.:Insti-tuteofEducationSciences,U.S.DepartmentofEducation.RetrievedApril6,2015fromhttp://nces.ed.gov/nationsreportcard/pdf/main2002/2003529a.pdf

NationalCenterforEducationStatistics.

(2012a).Lessonslearnedfromthe2012Grade4WritingComputer-basedassessmentstudy.Washington,D.C.:InstituteofEducationSciences,U.S.DepartmentofEducation.RetrievedApril6,2015fromhttp://nces.ed.gov/nationsreportcard/subject/writing/pdf/grade_4_writing_summary.pdf

NationalCenterforEducationStatistics.

(2012b).TheNation’sReportCard:Writing2011(NCES2012–470).Washington,D.C.:InstituteofEducationSciences,U.S.DepartmentofEducation.RetrievedApril6,2015fromhttp://nces.ed.gov/nationsreportcard/pdf/main2011/2012470.pdf

Santangelo,T.,Harris,K.,&Graham,S.(2008).

Usingself-regulatedstrategydevelopmenttosupportstudentswhohave“trubolgitingthangsintowerds.”RemedialandSpecialEducation,29,78-89.

Sturm,J.,&Rankin-Erickson,J.(2002).Effectsof

hand-drawnandcomputer-generatedconceptmappingontheexpositorywritingofmiddleschoolstudentswithlearningdisabilities.LearningDisabilitiesResearchandPractice,17,124-139.

Troia,G.,&Graham,S.(2002).Theeffectiveness

ofahighlyexplicit,teacher-directedstrategyinstructionroutine:Changingthewritingperformanceofstudentswithdisabilities.JournalofLearningDisabilities,35,290-305.

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Zumbrunn,S.,&Bruning,R.(2012).Improvingthewritingandknowledgeofemergentwriters:Theeffectsofself-regulatedstrategydevelopment.ReadingandWriting:AnInterdisciplinaryJournal,26,91-110.

AppendixASampleLessonPlanProvidedfortheTeachersLesson13.ModelItPurpose:IdentifyingtheMainIdeaandImportantIdeasa.Mini-lesson

i. Readashortstorytothestudents.ii. Thinkaloudwhileyoushowthemhowtowritethemainidea.iii. Rereadthestory,themainideaandotherimportantideasyou’velisted.Thinkaloudwhileyou

modeltheself-statement,“HaveIwrittenthemainideaandalltheimportantideas?”b.StudentWritingIdea:

i. Askstudentstoreadashortstoryorportionofastoryii. Askstudentstowritethemainideaandotherimportantideasaboutthestorytheyread.iii. Encouragethemtocheckwhatthey’vedoneandaskthemselves,“HaveIwrittenallofthe

importantideas?”

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OpinionParagraphWritingInterventionforStudentswithSignificantDisability

PamelaJ.Mims,EastTennesseeStateUniversity

CarolStanger,AttainmentCompanyRobertPennington,UniversityofLouisville

WendeeWhiteJulieSears

NancyStricklerEastTennesseeStateUniversity

AbstractIncreasingly, technologyhasbeenused toprovideaccess to academic curricula for students withmoderate to severe intellectual disability. In thecurrentpilotstudy,weusedamultipleprobeacrossparticipantsdesigntoevaluatetheeffectivenessofa technology-based instructional package on theopinion writing skills of three middle school stu-dents with moderate and severe intellectualdisability.Findingssuggestthattheinterventionre-sulted in improved performance across all threeparticipants and that all participants maintainedperformance at levels greater than baseline.Limitationsandimplicationsforpracticeandfutureresearcharediscussed.Keywords: writing intervention, assistive technol-ogy,autism,intellectualdisability

IntroductionArecentshiftinthefocusofinstructionforstudentswithmoderate to severe intellectual disabilityhasaffordednewopportunitiesforparticipationinthe

general education curriculum. This change,precipitated by legislative calls for accountability(e.g.,NoChildLeftBehind[NCLB],2002;IndividualswithDisabilitiesEducationImprovementAct[IDEA],2004) and the promise of an emerging body ofresearch on the effectiveness of academicinterventionforstudentswithmoderateandsevereintellectual disability (e.g., Hudson, Browder, &Wood, 2013; Spooner, Knight, Browder, & Smith,2012), necessitates that educators reconsidercurricula for this unique population. That is, theymust expand upon a well-established concept offunctionalcurriculum(Brownetal.,1979)andadoptnew expectations related to performance inacademiccontexts.This expanded vision for educating students withmoderateandsevereintellectualdisabilityincludestheexpectationthatallstudentsmakeprogress inthegeneraleducationcurriculumandworktowardachieving college readiness skills. Central to theseaimsisthedeliveryofhighqualityinstructionintheareaofliteracysothatstudentscanmoreeffectivelyacquire and demonstrate their understanding ofcontent knowledge through reading, writing,

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speaking, and listening (Kearns et al., 2010).Unfortunately,themajorityofresearchonliteracyinstructionforstudentswithmoderateandsevereintellectual disability has focused narrowly onreading sight words (Katims, 2000). Only recentlyhave researchers turned their attention to otherskillsthataretargetedduringliteracyinstructionforstudents with moderate and severe intellectualdisability. Several research teams have looked tothe English Language Arts (ELA) benchmarks, asdefined in the Common Core State Standards, forguidance (Conley, 2007; Kearns et al., 2010;Spooner & Browder, 2015) and have designedeffectiveinterventionsforteachingarangeofskills(e.g., Hudson et al., 2013; Hudson, Browder, &Jimenez, 2014;Mims, Hudson, & Browder, 2012).These important advances in the technology ofteaching for students with moderate and severeintellectual disability further support the need foranincreasedresearchemphasisoninterventionforthiscriticalsetofskills.Despite the emergence of soundmethods for theinstruction of studentswithmoderate and severeintellectualdisabilityinreading,therehasbeenlittleworkintheareaofwrittenexpression(Pennington&Delano,2014).Writtenexpressionplaysacriticalroleinthelivesofallstudentsasitservesarangeoffunctions in educational settings. Students usewriting to demonstrate their understanding ofcontentacrossacademicareas,tosharetheirideasabouttheworld,andtoengageinsocialinteractionswithpeers.Furthermore,writingskillsareessentialto college and career readiness as they arenecessary for success across a range of tasks inpostsecondary environments. Unfortunately, datasuggest that many students with and withoutmoderate and severe intellectual disability havedifficultyacquiringproficiencyinwrittenexpression(U.S. Department of Education, 2011). Writtenexpression is complex and involves thesimultaneousexecutionofaconstellationofskillstogenerate a specific message for a particularaudience. This task is often more difficult forstudents with moderate and severe intellectualdisability as they may present deficits in social

communication, fine motor skills, readingcomprehension,andperspective-taking.Fewresearchteamshaveinvestigatedstrategiesforteaching writing to students with moderate andsevere intellectual disability. Two reviews of theresearch literature on writing interventions forstudents with intellectual disability (Joseph &Konrad, 2009) and autism spectrum disorder(Pennington & Delano, 2012) indicated that themajority of investigationswere applied to spellingandwordconstructiontasks,but few involvedtheproductionofwrittennarratives. Theauthors alsonotedthatexplicitinstruction,assistivetechnology,andpredictablewriting routineswere consistentlyapplied as an intervention component. Morerecently,researchteamshaveappliedvariationsofthese components to a range of writing skillsincluding spelling (Purrazzella & Mechling, 2013),story writing (Pennington, Ault, Schuster, &Sanders, 2011; Pennington, Collins, Stenhoff,Turner, & Gunselman, 2014), using personalnarratives within text messages (Pennington,Saadatzi,Welch,&Scott,2014),andwritingresumecover letters (Pennington, Delano,& Scott, 2014).Across these studies, researchers consistentlyapplied response prompts (i.e., simultaneousprompting,systemofleastprompts,timedelay)butemployeddisparateformsoftechnology(i.e.,robottechnology, commercial writing software, tabletpersonalcomputers).The frequent application of technology-aidedinstruction (TAI) during writing intervention forstudents with moderate and severe intellectualdisability is not surprising as it offers severaladvantages to the emerging writer. First, writersmayusesoftwarethatallowsfortheconstructionofwritten products in the absence of a spellingrepertoire (Pennington, 2016). For example,studentsmayselectawordfromasoftwarearraytocomplete a sentence about a picture, or selectmultiplewordstoconstructasentenceaboutwhatthey read. Second, the digital presentation ofinstructional stimuli about which the student isexpected towritemaybedesigned in suchaway

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that relevant stimuli might be highlighted orrepeated. This increased salience of instructionalstimulimayfacilitatestudentattentionandstimuluscontrol. Finally, some students’ preferences forparticular featuresofthetechnologymayservetoreinforcetheirwritingbehavior(Pennington,2010).DatasuggestthatsomestudentspreferTAIinlieuoftraditionalteacher-deliveredintervention(Moore&Calvert,2000). In lightof theseadvantages, futureresearch in writing and moderate and severeintellectualdisabilitywill likely include innovationssteepedinTAI.The current literature on teaching writing to stu-dents with moderate and severe intellectualdisabilityispromisingandsuggestsapathforward(i.e.,explicit instruction, technology) indevelopingmore complex literacy repertoires for thispopulationofstudents. Interestingly, theguidanceoffered by the literature reflects practiceinconsistent with established guidelines forteaching writing; that is, themajority of researchteams have focused on writing withoutconsideration of ongoing reading instruction.Written expression plays a critical role in readingcomprehension.Whenstudentsareaskedtowritein the context of academic instruction, they areprovided with opportunities to make decisionsabout and therefore, reexamine the content(Graham&Harris,2016). In thecurrent study,wesought to investigate the effectiveness of atechnology-based instructional package on theopinion writing skills of three middle schoolstudents with moderate and severe intellectualdisability. The package included the digitalpresentationofgrade-alignedtextandsubsequentinstructiononwritinganopinionaboutthetext.Weaddressed the following research questions: (1) Isthere a functional relation between the use of atechnology-aidedinterventionpackageandtheper-cent of correct steps performed during students’opinionwritingtasks?and(2)Whatistheeffectofatechnology-based,task-analyzedwritinginterven-tion on the social validity as reported by theteacher?

TargetAudienceandRelevanceIn light of a limited body of research to guidepractitioners in teaching writing to students withdevelopmentaldisabilities,thispaperdemonstratesaneffectiveapplicationofassistivetechnology(AT)within the writing process for students acrossgrades 5 to 8. This papermay serve as a startingpointforarangeofpractitioners(e.g.,generalandspecial education teachers, speech-languagepathologists,assistivetechnologyspecialists)work-ingwithstudentswithdevelopmentaldisabilitiesindesigning rich, grade-aligned ELA instruction thataddresses skills in both reading and writtenexpression.

MethodParticipantsandSettingsThreeparticipants,ages10to14years,withmoder-ateandsevereintellectualdisabilityparticipatedinthestudy.Allthreestudentsreceivedspecialeduca-tionservicesinamiddlegradesself-containedclass-room(5thgradethrough8thgrade).ELAinstructionintheclassroom,atthetimeofthestudy,focusedonearlyliteracyorearlyreadingskillbuildingusingelementary aged books. Little to no grade-alignedELA instruction occurred in the classroom. Theparticipantsmetthefollowinginclusioncriteria:(a)educational eligibility for autism and/or anintellectuallydisability,(b)useoftheselectanddragfeatureonan iPad, (c) participation in statealter-nate assessment based on alternate achievementstandards, (d) regular school attendance, and (e)visualandauditoryacuity.Allthreeparticipantshadprevious experience using an iPad in educationalsettings.Studentsselectedtheirownpseudonyms.Frodowasa10-year-oldCaucasianfemaleinthe5thgrade. Frodowas identified as having amoderateintellectualdisability.Frodousedacombinationofspokenwordsandpicturesymbolstomakerequestsandhadlittletonoexposuretograde-alignedtextorgrade-alignedELAinstruction(SeeTable1).Jay was a 14-year-old Caucasian male in the 6th

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grade. Jay was identified as having a moderateintellectual disability and primarily used picturesymbolstocommunicate.Jayhadlittletonoexpo-sure to grade-aligned text or grade-aligned ELAinstruction(SeeTable1).

Shrekwasa14-year-oldCaucasianmaleinthe8thgrade.Shrekalsowasidentifiedashavingasignifi-cantintellectualdisabilityandusedpicturesymbolstocommunicate.Shrekhadlittletonoexposuretograde-alignedtextorELAinstruction(SeeTable1).

The interventionist was a graduate researchassistant with five years of experience in workingwithstudentswithmultipledisabilitiesandbehaviorconcerns. The interventionist and a graduateassistant (i.e., doctoral student in early childhoodeducation), who conducted inter-observerreliability and procedural fidelity checks, weretrained to conduct baseline and interventionprocedures.

The researchers conducted the study in a ruralpublic middle school in the southeastern United

States.Sessionswereconductedatleastthreetimesa week for five weeks of intervention. Sessionsoccurredinaroomattachedtothestudent’sregularclassroom. Each session lasted approximately 40minutes.

Materials

Adaptedstory.AnadaptedversionofOutsiderswasreadaloudviaastandalone iPadapp,Access:Lan-guage Arts (Attainment Company, 2016) withprofessional narration (a professionally recordedvoice, as opposed to a text-to-speech ‘robotic’voice). The adapted version of Outsiders wasrewrittenat3.5gradelevel,dividedintofivechapterpairings with reduced text and picture supports.Eachchapterpairingcontainedtwochapters(i.e.,1and2,3and4,etc.)andrangedfrom11-14pagesinlength.Picturesupportswereusedforkeyvocabu-larywords,primarilynounsandverbs,andcharac-ters.Eachpageheldapproximately42wordsand10picturesupports,alongwithunderlinedvocabularywords.Eachpagewasreadaloud,viatheapp,andat the end of each page the student pushed the

Table1ParticipantDemographics

Student/Gender/Ethnicity

Age/Grade IQTestGiven/IQ Disability Reading/VocalVerbalAbility

Frodo/Female/Caucasian

10/5th WISC-IV/50 SignificantIntellectualDisability

Non-Reader/VocalVerbal

Jay/Male/Caucasian

14/6th WISC-IV/<50

SignificantIntellectualDisability


Shrek/Male/Caucasian

14/8th WISC/<40 SignificantIntellectualDisability


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arrow to proceed to the next page. Students alsowere able to press the underlined vocabulary fordefinitions. Each chapter pairing took approxi-mately20to25minutestoread.iPadapp.GoBookapp(Attainment,2015)wasusedtodevelopawritinginterventiontoaccompanytheOutsidersstory.TheGoBookapppresentedvocabu-lary words (e.g., brother, group), instructionalwords (e.g., setting, main character, conclusion),andanoverviewofthetypesofsentencesrequiredforwritingaparagraph(i.e., introduction,opinion,fact, conclusion). The GoBook app used text-to-speechforthewritinginstructionandintervention,asopposedtoahumanrecordedvoiceaswasusedintheadaptedstory.Writing intervention. During the writing activity,GoBook presentedadisplaywitha statementandthreeoptionsfromwhichstudentsmadeaselectionby touching the choice on the iPad screen. Wedesigneddisplaysfortheselectionofidentifying:(a)awritingtopic,(b)anopiniononthechosentopic,(c)afactthatsupportedtheidentifiedopinion,(d)asecond fact that supported the identifiedopinion,(e)aconclusionstatement,and(f)anopportunitytochangeopinions.Inaddition,pageswerecreatedtoaddress error corrections, as needed, and pageswere created that allowed the students anopportunity to write their chosen responses bycompletingsentencesthroughtheuseofdraganddrop. More specifically, when presented with ascreen with the question, “What will you writeabout?”threechoiceswerepresentedincludingonedistractor(i.e.,acharacter,abigidea,orarandomtopicnotrelatedtothestory).Afterchoosingasub-ject to write about, the next display asked aboutwhichspecificstorytopictheparticipantwantedtowrite. For example, “Who do you want to writeabout? Cherry, Pony-boy, or Michelle Obama.”Again, two correct answers andone far distractorwere presented. Next, the student established anopinionaboutthetopicselected.Thenexttwodis-plays were designed to identify the facts thatbackedupthestudent’sopinion.Thedisplayscreenasked, “Which fact supports your opinion?”

followedbyawritingpromptthatfilledinthestu-dent’s opinion from the prior page (e.g., I thinkPony-boyisnicebecause______”).Thispromptwasfollowed by three response options including thecorrect answer, a response containing a fact thatsupported the opposite opinion, and a responsethatdidnotoccurinthestory.Ifthestudentschosethe opposing responseoption, then theywere di-rectedtoapagethatprovidedthemanopportunitytochangetheiropinionorchangetheirfactchoice.Lastly,ontheconclusiondisplay,thescreenasked,“What is the last sentence you want to writeabout?”Aconclusionstatementfortheanswerwasgiven, (i.e.,“Inconclusion, I thinkPony-boy isnicebecause…”)alongwiththreechoices.Eachdisplaypagehadpicturesupportsnexttothechoicesandpicturesupportsforkeywordssuchassentence type and characters. If the studentselected distractors, GoBook implemented errorcorrectionprocedures,firstinformingtheuserthatthe selection was incorrect, then eliminating(grayingout)theoption.Inaddition,thefactques-tionincludedahintbuttonlocatedatthebottomofthe screen. When students used this button, thescreen went to the page of the story where theanswer was located. The interventionist read thispagealoud to the student, thenwentback to thefact question. Interactive drag and drop screenswereplacedinbetweeneachdisplayquestionpage,where studentswere to touchandmove the sen-tences into the paragraph. After the interactivepagecameacompletedparagraphwithataskanaly-sis chart showing sentence number and sentencetypewithcheckmarkstoindicatecompletion.Thewriting intervention took approximately 10 to 15minutestocomplete.SeeTable2foranoverviewoftheintervention.ResearchDesignTopilottestandevaluatetheefficacyofthewritingintervention, the researchers used a preliminaryconcurrentmultipleprobeacrossparticipantssinglesubjectdesign(Horner&Baer,1978).Baselinedata

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Table2.1WritingIntervention

Pre-WritingActivitySteps DisplayScreen PracticeUtilizedAppreadsstoryaloudtostudent,whilestudentpushesarrowtoadvancepages

ChapterpairingofOutsidersadaptedstory

Readaloud

Paragraphvocabularyandinstructionalvocabulary

Four(4)vocabularywordsstudentswillseeforchoices(e.g.excited,horrible,disappointed,andunlucky)Introduction,Opinion,FactandConclusion

ReadaloudModel,Lead,Test(Myturn,ourturn,yourturn)Studenthasreadaloud

Paragraphstructure Introduction,Opinion,Fact,SupportingFact,andConclusionwithDefinitions

Readaloud

WritingActivitySteps DisplayScreen PracticeUtilizedIntroductioninstruction Theintroductionisthefirst

sentenceinyourparagraph.Intheintroductionyoutellwho,orwhat,wearewritingabout.

ReadaloudInterventionistasks,“Whatisthefirstsentence?”

Introductionwriting Whatwillyouwriteabout?Acharacterandsetting,abigidea,orabird?

Timedelayof5s,errorcorrection,leastintrusiveprompts

Introductionwriting Who/Whatdoyouwanttowriteabout?Ponyboy,Cherry,orGeorgeWashington?

Timedelayof5s,errorcorrection

Draganddropintroductionblank

Inthischapter,_______isamaincharacter.

Draganddropwithleastintrusiveprompts,timedelayof5s,readaloudsentenceforreview

Opinioninstruction Inyoursecondsentence,youwillwriteyouropinion.Anopinionisaviewpoint.Youshareyourthoughts,feelings,orbeliefsaboutsomethingorsomeonefromthestory.

Readaloud.Interventionistasks,“Whatisthesecondsentence?”

Opinionwriting WhatisyouropinionofPonyboy?IthinkPonyboyis______.Nice,trouble,orscientific


Draganddropintroductionandopinionsentences

Dragyourintroductionandopinionsentencesintotheboxtostartconstructingyourparagraph


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WritingActivitySteps DisplayScreen PracticeUtilizedSentencechartreview Nowyouhaveyourfirsttwo

sentences.Let’sreadyourparagraphsofar:Inthischapter,Ponyboyisnice.Ithinkheisnicebecausehelooksoutforhisfriends.Anotherreason…

Readaloudandreview.Completedsentencesandsentencetypes

Factinstruction Next,youneedtosupportyouropinionwithafactfromthestory.Afactisadetailofpieceofinformationfoundinthestory.

Readaloud.Interventionistasks,“Whatisthethirdsentence?”

Factwriting IthinkPonyboyisnicebecause_______.Helooksoutforhisfriends,hesnuckintothetheaterwithoutpaying,helikestobakecakes.


Changeopinion(onlyiswrongchoiceofopinion)

Sneakinginthetheaterwithoutpayingisnotnice.DoyouwanttochangeyouropinionofPonyboyfrom“Ponyboyisnice”to“Ponyboyistrouble”?Yes,IhavechangedmymindorNo,Iwanttochangemyfact.

Studentchooses.Ifselectiontochangeopinion,gobackto“Whatisyouropinionof____?”andrepeatremainingoptions(onlyonetime).Ifselects“No,”allowtocontinuewithwritingparagraph.

Draganddropfactsentence Dragyourfactsentenceintotheboxtostartconstructingyourparagraph.


Sentencechartreview Nowyouhaveyourfirstthreesentences.Let’sreadyourparagraphsofar:Inthischapter,Ponyboyisamaincharacter.IthinkPonyboyisnice.Ithinkheisnicebecausehelooksoutforhisfriends.Anotherreason…

Readaloudandreviewcompletedsentencesandsentencetypes

Factinstruction Remember,afactisadetail,orpieceofinformationfromthestorythatsupportsyouropinion.YouwrotePonyboyisnice.Youneedtofindanotherfacttosupportyouropinion.

Readaloud.Interventionistasks,“Whatsentenceisnext?”

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WritingActivitySteps DisplayScreen PracticeUtilizedFactwriting Chooseanotherfactthat

supportsyouropinionthatPonyboyisnice.AnotherreasonIthinkPonyboyisniceisbecause________.Hemadefriendswiththegirls,hestayedoutlate,hehasabicycle


Draganddropfactsentence Dragyourfactsentenceintotheboxtostartconstructingyourparagraph.


Sentencechartreview Nowyouhaveyourfirstfoursentences.Let’sreadyourparagraphsofar:Inthischapter,Ponyboyisamaincharacter.IthinkPonyboyisnice.Ithinkheisnicebecausehelooksoutforhisfriends.AnotherreasonIthinkPonyboyisniceisthathemadefriendswiththegirls.

Readaloudandreviewcompletedsentencesandsentencetypes.

Conclusioninstruction Thefinalstepistowritetheconclusion.Theconclusioniswhereyousummarizeyourparagraph.

Readaloud.Interventionistasks,“Whatisthelastsentence?”

Conclusionwriting WhatisthelastsentenceyouwanttowriteaboutPonyboy?Ithinkitisgoodthat______.Ponyboyisnice,JohnnyisPonyboy’sfriend,Ponyboylikesmonkeys


Sentencechartreview Welldone!Youhavecreateda5sentenceparagraph:Inthischapter,Ponyboyisamaincharacter.IthinkPonyboyisnice.Ithinkheisnicebecausehelooksoutforhisfriends.AnotherreasonIthinkPonyboyisniceisthathemadefriendswiththegirls.Inconclusion,IthinkthatitisgoodthatPonyboyisnice.

Readaloudandreviewcompletedsentencesandsentencetypes

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were collected for a minimum of three sessionsacrossparticipants.Oncedatawere stable for thefirstparticipant,weintroducedtheinterventionandcollecteddataacrosstheremainingstorychapters.Onceweobservedachangeineachparticipant,weintroducedtheinterventiontothenextparticipantand continued across the remaining chapters.Wecollected and grapheddata on the percent of un-prompted correct responses across baseline,intervention,andmaintenancesessions.DependentVariablesandDataCollectionThedependentvariablewasthepercentofcorrectsteps performed during students’ opinion writingtasks.Wescoredstepsasperformedcorrectlyifthestudent independentlydraggedacorrectresponsein position to complete the sentence within 5seconds.Fortopicandopinionstatements,studentswere required to select one of two correctresponses. For supporting facts and conclusionstatements, students were required to select asingleaccurateresponse.Duringthebaselinecondi-tion, the interventionist readeachwritingpromptandwaited5secondsforastudentresponse.A“+”wasrecordedforacorrectresponseanda“–”wasrecordedforanincorrectornoresponse.Duringtheinterventionsessions,theinterventionistscoredthestudents’levelofpromptneededtocompleteare-sponse. An “I” was recorded for independentcorrect, “V” for verbal prompt, “M” for modelprompt,and“P”forphysicalprompt.To facilitate engagement during each session, theinterventionistredirectedtheparticipanttolookatthe iPad and participate by turning the page. Thelevel of engagement for each student was ratedweeklyusingthefollowingscale:1)Doesnotpartici-pateatall(e.g.,doesnotlookat/inthedirectionoftheiPad);2)Passivelyparticipates(e.g.,looksattheiPad or teacher as they respond, but makes noattempt to respond to teacher directions or iPadapplication directions without assistance); 3)Occasionallyparticipates(e.g., looksatthe iPadorteacher as they respond and makes attempts torespondtolessthanhalfofthequestionsasked);4)

Usually participates (e.g., looks at the iPad orteacher as they respond and makes attempts torespondtoatleast50%ofthequestionsasked);5)Activelyparticipatesmostofthetime(e.g.,looksatthe iPad or teacher as they respond and makesattempts to respond to more than 75% of thequestionsasked);and6)Activelyparticipatesallofthetime(e.g., looksattheiPadorteacherastheyrespond and makes attempts to respond to allquestionsasked).Procedural fidelity and interobserver agreement(IOA).Asecondobserverscored33%ofthebaselineandinterventionsessionsusinganimplementationfidelity checklist.Wecalculatedprocedural fidelitybydividingthenumberofstepsdeliveredcorrectlybythetotalnumberofproceduralstepsandmulti-plied by 100. Procedural fidelity for baseline andinterventionsessionswas98%(94%-100%).AthirdresearchercollectedIOAdataon66%ofproceduralfidelityobservations.WecalculatedIOAbydividingthe numbers of agreements by the number ofagreementsanddisagreementsandmultiplyingby100.IOAwas92%(rangeof85-100%).We also calculated IOA on the number of correctstudentresponsedatafor29%ofthebaselineandinterventionsessions.IOAwascalculatedbytakingthenumberofagreementsdividedbythenumberofagreementsplusdisagreementsandmultiplyingby100. IOA forbaselineand interventionsessionswas94%(rangeof91-100%).Social validity. At the end of the study, the re-searcher collected social validity data on the pur-pose,process,andoutcomeofthestudyfromtheclassroom teacher. The special education teachercompleted a social validity questionnaire with 16Likert scale items and several open-ended ques-tions.Likertscaleitemsincludedquestionssuchas:“Wastheapplicationsuccessfulinengagingthestu-dent?” “Were the picture icons helpful?” “Werelearningpartsoftheparagraphavaluableactivity?”and“Inoticedtimeontaskincreasedforotherclass-room activities.” Open-ended questions were inalignmentwith the Likert-scale questions to allow

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the teacher to expound on student observations.Teacher answers gave further insight toquestionssuch as: “To what extent did your student showengagement?” “Were there toomany or too fewpictureicons?”and“Doyoulikeusingyourownsys-temofleastpromptsandpraiseorwouldyoupreferthattobebuiltintotheprogram?”

Procedures

Baseline.The interventionistandstudentsatside-by-sidewiththeiPadplacedbetweenthem.Thestu-dentslistenedtoachapterpairing(insequence)ofthe adapted text, Outsiders read by the Access:Language Arts app. After the read-aloud, theinterventionist opened the writing activity in theGoBookapp.GoBookpresentedthefollowingseriesofspokenprompts:(a)Whatwillyouwriteabout?(eitheramain character,big idea,or settingwerepresented as options); (b) Who/Where/What doyouwanttowriteabout?(thisvarieddependingonthe topic chosen); (c) What is your opinion of_____?(filledinwithspecificwho,what,orwhereidentifiedfrompriorstep);(d)Whichfactsupportsyouropinion?(e)Chooseanotherfactthatsupportsyouropinion;and (f)What isyourconclusionsen-tence?Threeresponseoptionswerepresentedwitheach prompt (e.g., I think Ponyboy was good be-cause…. he was nice to Cherry; he was mean toCherry;abus).Betweeneachoftheabovewritingprompts, the student had an opportunity to draganddropmissingwordsfromthesentenceintothecorrectblanks.Forexample,thefollowingsentencewouldappear“Ithink______wasgoodbecausehewas_____toCherry.”andthestudentwouldhavetodraganddropthemissingwords(Ponyboy;nice)intothecorrectblankspace.Studentsweregiven5seconds to initiate a response for filling in theblanks.Ifthestudentrespondedcorrectlytoawrit-ing prompt, the interventionist scored a “+” on adata collection sheet. If the student selected anincorrect response or did not respond within 5seconds,theinterventionistscoreda“-”.Through-outbaseline,prompting topromoteacorrect stu-dentresponsewasnotprovidedandreinforcementfor a correct response or error correction for an

incorrectresponsewasnotprovided.Studentswerepraised for attending behaviors throughoutbaseline.

Intervention. At the onset of each interventionsession, the student listened to a reading of thetargeted chapters from Outsiders in the Access:Language Arts app. Once the read-aloud wasfinished,theinterventionistintroducedthewritingactivityintheGoBookapp.First,theinterventionistpresented five targeted vocabulary words associ-ated with the opinion paragraphs (i.e., sentence,paragraph, fact, introduction, conclusion).GoBookpresented each word and read each definitionaloud. Second, the interventionist presented thefive-sentence paragraph structure (i.e.,introduction, opinion, fact, fact, conclusion) usingGoBookandamodel, lead,testprocedure(Larkin,2001).Theinterventionistmodeledafive-sentenceparagraphusingagraphicorganizerwithintheapp.Theinterventionistpresentedthesentencedescrip-tion (i.e.,“The introduction is the firstsentence inyourparagraph.Theintroductiontellswho,orwhatwearewritingabout.”)whiletouchingtheintroduc-tionbuttonpreprogrammedintotheapp.Thentheinterventionist and the student pressed theintroduction button together. Finally, the studentindependently pressed the introduction button tostate the rule. This instruction continued for theremainingpartsoftheparagraph.Afterinstructionon the sentence type, the students applied theirknowledge by creating their own five-sentenceopinionparagraphs.GoBookpresentedthestimulus“Whattopicdoyouwanttowriteabout?”andpre-sented three response options. If the student re-sponded incorrectly, GoBook presented an errorcorrectionandanauditoryprompt,“The(incorrectresponse)wasnotapartofourstory.”Theappthenrepeatedthestep,butwiththeincorrectresponseoptionhighlightedingrayandinactive.Thisprocesswasrepeateduntilthestudentselectedthecorrectresponseorwasleftwithasinglecorrectresponse.Ifthestudentdidnotrespondwithin5seconds,theinterventionist implemented a system of leastprompts procedure. First, the interventionistpresentedaverbalpromptandwaited5secondsfor

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the student to respond. If the student did not re-spond,theinterventionistpresentedthenextlevelofpromptinapredeterminedhierarchy(i.e.,verbalprompt,modelprompt,physicalprompt).Afterthestudentidentifiedatopic,thenextscreenintheapppresented an opportunity for the student to draganddrop their response to complete an introduc-tion sentence (e.g., I want to write about____________).Theirnewlycreatedsentencewasplaced into a graphic organizer in the “introsentence” spot as the first sentence. This sameprocess continued until the student identified allsentences in the five-sentence opinion paragraph(i.e., their opinion, two supporting facts from thestory, and a matching conclusion). Students werepresented with the same chapter pair for threeconsecutive sessions, but had an opportunity towrite about a new topic and opinion each time.Subsequently,wepresentedasinglebaselineprobeon the next chapter pair before enteringinterventionwiththatchapterpair.Weconductedthese probes to assess whether students hadgeneralized their paragraph writing skills tountrained chapter content. We collectedmaintenance data approximately twoweeks afterthestudentsfinishedtheintervention.Maintenanceprobeswereconductedusingprocedures identicaltothoseinbaselineconditions.

ResultsThepercentofcorrectstepsperformedduringstu-dents’ opinion writing tasks during baseline andintervention sessions are depicted in Figure 1.Frodo’s performance was stable during baselinesessions (i.e., 50% across all three probes).Following the introduction of intervention onChapters1and2,herperformanceimprovedtoanaverage73%ofcorrectsteps(i.e.,70,70,80%).Priorto intervention on Chapter 3 and 4, Frodoperformed60%ofstepscorrectly.Duringinterven-tion on Chapters 3 and 4, Frodo averaged correctperformanceof53%ofsteps(i.e.,30,60,70).Priorto instruction, on Chapters 5 and 6, Frodocompleted60%ofsteps,whereasduringinstructiontheaveragewas63%of completed steps (i.e., 50,

60,80).Finally,priortoinstructioninChapters7and8,Frodocompleted60%ofsteps.Followinginstruc-tion,67%of the steps (i.e.,60,70,70)werecom-pleted. At 4 and 5 weeks following intervention,Frodo completed 60% and 70% of steps,respectively. Overall, Frodo increased her meanperformance from baseline to intervention condi-tionsby14%andregardingeffectsize,thepercentof non-overlapping data (PND)were calculated at86%(Scruggs&Mastropieri,2001).Duringbaselinesessions,Jaycompletedanaverageof 52.5% of steps correctly (i.e., 60, 40, 60, 50).Following the introduction of intervention onChapters 1 and 2, Jay averaged a 40% correctcompletion of steps (i.e., 30, 50, 40). Prior tointervention on Chapters 3 and 4, Jay completed50% of steps correctly. During intervention onChapters3and4,Jayaveragedcorrectcompletionof70%ofsteps(i.e.,70,60,80).Priortoinstruction,onChapters5and6,60%ofstepswerecompletedcorrectly,whereasduringinstructionJaycompletedanaverageof73%ofstepscorrectly(i.e.,70,60,70).Finally,priortoinstructioninChapters7and8,Jaycompleted40%ofstepscorrectly.Followinginstruc-tion, 63% of stepswere completed correctly (i.e.,60,60,70).At3weeks following intervention, Jaycompleted 60% of steps correctly. Overall, Jay in-creased his mean performance from baseline tointerventionconditionsby7.5%withaPNDof38%.Shrek completed an average of 44% of stepscorrectly during baseline sessions (i.e., 50, 30, 50,50, 40). During intervention on Chapters 1 and 2,Shrekaveragedcorrectcompletionof73%ofsteps(i.e.,30,90,100).PriortointerventiononChapters3 and 4, 50% of steps were completed correctly.DuringinterventiononChapters3and4,Shrekaver-agedcorrectcompletionof63%ofsteps(i.e.,60,60,70).Priortoinstruction,onChapters5and6,70%ofsteps were completed correctly, whereas duringinstructionanaverageof67%of stepswere com-pleted correctly (i.e., 50, 70, 80). Finally, prior toinstruction in Chapters 7 and 8, Shrek completed50%ofstepscorrectly.Followinginstruction,Shrek

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Figure1Percentofunpromptedcorrectstepsinopinionwritingprocessacrossthechapterpairsofanadapted

versionofOutsiders.

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completed77%ofsteps(i.e.,70,90,70)correctly.At2weeksfollowingintervention,Shrekcompleted60%ofstepscorrectly.Overall,Shrekincreasedhismean performance from baseline to interventionconditionsby23.5%withaPNDof85%.SocialValidityOverall,theteacherreportedfavorableperceptionsof the study components.On the Likert scale, theteacherscoredfiveitemsas“stronglyagree”includ-ing(a)theappwasengagingtothestudents,(b)thereadaloudofOutsiderswasappropriateforthestu-dents,(c)thepictureiconswerehelpfulthroughthestories, (d) assessing the student’s ability tocorrectlyanswerquestionsinaguidedwritingactiv-ity is valuable, and (e) the incorrect-answerpages(pages with corrective feedback) were useful inhelping to re-direct students to make correctchoices during their writing activity. The teacherscored8itemsas“agree.”Theseitemsincluded(a)learningthepartsofaparagraphwasvaluable forher students to learn about writing, (b) studentsshowed an increase in vocabulary after theimplementation of the intervention, (c) time-on-taskincreasedaftertheappwasintroducedtothestudent, (d) the intervention was important andappropriate, (e) due to the app, her students hadbetter access, (f) due to the app, she was moreeffective in teaching age/grade appropriate ELAcurriculum, (g) the teacher was interested incontinuingtheuseofthewritingactivityinherclass-room,and(h)thehintfeaturewashelpfultothestu-dents. The teacher scored one item as “neutral;”(i.e.,theELAappwasmorerelevantthanwhatwaspreviouslyimplementedforELAinstruction).In addition,we asked the teacher to complete anopen-ended survey related to the instructionalpackage. Overall, the teacher’s responses werepositive. The teacher reported that studentswereincreasinglymoreengagedastheybecamefamiliarwith the app and activity. The teacher alsosuggested that the “right” number of picturesupportswereusedintheread-aloudstoryandthatshewouldprefer tocontinueusing theapp in the

classroom. The teacher reported that the averagelessonwasanappropriatelength(25-45min).How-ever,theteacherindicatedtheappmightbemoresuited for a 1:1 instructional arrangement andsuggested that “the paragraph definitions, para-graphstructure,andstoryisalotformorethanonestudenttostayengagedinasagroup.”Inaddition,theteacherwarnedaboutcarefulselectionofhighlydisparate distractors for future studies or implica-tions for practice as shementioned that some ofthesedistractorswere“funresponsesandgrabbedstudents’ attention.” The teacher offered severalrecommendations for the improvement of thewriting intervention app including (a) incorporatemore human-like voices, (b) embed additionalpositive feedbackpromptswithin theprogram, (c)reduce the number of words per page, and (d)ensure that the distractor item did not includepotentiallyreinforcingstimuli(i.e.,fooditems).EngagementInadditiontosocialvalidity,aweeklyself-reportedengagement rating was collected. While theengagement measure did not include a directmeasureofdailybaselineandinterventionsessions,the interventionist self-reported high levels ofengagementwithanoverallratingof5.12indicatingthatthestudentsactivelyparticipatedmostofthetime (e.g., looksat the iPador teacheras theyre-spondandmakesattemptstorespondtomorethan75% of the questions asked). Frodo’s and Shrek’saverageengagementscoreswere4.75,(range=3–6)and4.8(range=4-6),respectively.Jayshowedveryhigh engagement at 5.83, which indicated nearly100%engagementthrougheverysession,withtheexceptionofonesessionwitharatingof5.OutcomesandBenefitsInthecurrentinvestigation,theresearchersdemon-strated that students with moderate and severeintellectual disability could improve their skills inwritten expression, specifically opinion writing,whenprovidedwithappropriateassistive technol-ogy supports and explicit instruction. Participants

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used features of the GoBook app to circumventchallenges often consistent with moderate andsevere intellectual disability to produce apermanentproductdetailingtheiropinionaboutanadapted and grade-aligned fictional novel. Forexample,GoBookpermitted studentswith limitedspellingrepertoiresandfinemotorimpairmentstoconstructnarrativesbydraggingwholewordsfromachoicearraytocompletesentences.Furthermore,the GoBook package incorporated a range ofsupportsforemergingreadersincludingstorynarra-tion,integratedvocabularyinstruction,andhintsforsupportedwordselection.Thesefactorsmayhavecontributedtotheoverall,interventionistreported,highlevelsofengagementbythestudentswhileus-ingGoBook.It is also important to note that GoBookincorporatedresearch-basedpromptingproceduresthat minimized the need for an adult interactionduring instruction.Theuseof increasinglyautono-mous instructional software is critical for studentswithmoderateandsevereintellectualdisabilityasitmay increase the time that students are able toworkwithoutadultassistance,perhapspromotingthe view that persons with moderate and severeintellectual disability can be active participants intheir own learning. In addition, this investigationtargetedtheselectionandsupportingofstudents’opinions. Though in the current study, opinionswere directly linked to a specific and limited con-text, it is important to note the instruction ofexpressinganopinionisconsistentwithprinciplesofpromoting self-determination for persons withmoderateandsevereintellectualdisability.

DiscussionThe purpose of this investigationwas to evaluatethe effectiveness of a technology-based instruc-tional package on the writing skills of threeparticipantswithmoderateandsevere intellectualdisability.Despitevariabilityinperformanceacrossparticipantsand instructionalunits (i.e., chapters),allparticipantsimprovedtheirperformanceinwrit-ing tasks from baseline to intervention conditions

and in a relatively short period of time.Furthermore,theymaintainedlevelsofrespondingabove those during baseline conditions. Thesefindings are promising in that they suggest thatstudents with moderate and severe intellectualdisabilitycanbenefit fromTAIthatsimultaneouslytargets skills in reading and written expression.Interestingly, only Frodo demonstrated animprovementfrompretreatmentbaselineprobestoprobes conducted prior to introducing a newchapterpairing.Anincreaseinstudentperformanceon these chapter probes might suggest thegeneralizationofwritingskillstonovelcontent.Thislackofgeneralizationacrossparticipantsmayhavebeenaresultofexposuretoaninsufficientnumberof exemplars (e.g. different reading passages)and/orthelimiteddurationofthestudy.Thecurrent interventionpackagereflectsadepar-turefromtheextantliteratureonwritinginstructionforstudentswithmoderateandsevereintellectualdisabilitybutisconsistentwiththedevelopmentofwritten expression in general education settingswhereby students continuously apply a range ofwritingskillsacrossmultipleareasofacademiccon-tent. Students in the current studywere taught aclusterofwritingskills includingvocabularyusage,sentence completion, paragraphorganization, andopinionwritinginthecontextofgradeappropriatetext. This complexitymayhavecontributed to thelimited improvement across participants whileobscuringprogressacrossskillsindependentofeachother.Furthermore, this investigation served to pilot anewsoftwareapplicationforteachingwritingskillsto studentswithmoderateand severe intellectualdisability.Severalapplicationshavebeendevelopedforsupportingstudentswithdisabilitiesduringwrit-ingactivities.Themajorityof theseprogramspro-vide students with accommodations (e.g., text tospeech)ormodifications (e.g.,wordbanks)duringtheproductionoftext.Unfortunately,therearefewprograms that embed explicit writing instructiontargetedfor thispopulation.TheGoBookapppro-vided controlled presentation of instructional

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stimuli,prompts,andfeedback.Thesefeaturesareadvantageousastheymayresultinfewererrorsininstructional delivery and greater studentindependence from adult supervision duringinstruction.Finally,thecurrentstudymayservetoinformnewinnovations in the development of morecomprehensive literacysoftware for studentswithmoderate and severe intellectual disability. Forexample, teacher feedback and studentperformance indicate a need for the reduction oftheamountoftextdisplayedoneachscreenandanincreaseduseofprogrammedpositivefeedback inordertoencourageengagement.Itisalsoimportantto note that the authors aligned instructional tar-gets within the app to grade appropriate ELAstandards. This featuremayenhance theutilityoftheapp,asteachersandpeerswithoutdisabilitiesmayfinditeasiertoincludestudentswithmoderateand severe intellectual disability in generaleducation instruction. This alignment also posesnewchallengesforresearchersandprogrammersinthe development of TAI that is aligned fromkindergartentograduation.Despite our overall positive findings, severallimitationsmustbeaddressed.First,weconducteda single probe prior to the introduction ofintervention for JayandShrek.Though thesedatawereconsistentwiththepatternsexpressedinthefirst threebaselinedatapoints, it isplausible thatthese data may not have accurately reflectedparticipants’steadylevelofresponding.Second,wedidnotassess student’s readingof thewordsandpicturesusedwithintheadaptedtextandapportheengagementwiththeunderlinedvocabularywordswithintheadaptedtext.Thoughallvocabularywaspresentedastextorpicturesandinadigitizedvoice,variabilityinstudentsreadingrepertoiremayhaveimpacted performance across chapters. Third, theamountofcontent(numberofpages)programmedinto the pilot GoBook app triggered instability,resulting in intermittent malfunctions in the soft-ware. Thesemalfunctions required the student towait while the program rebooted and potentially

affectedstudents'motivationandtheirsuccesswiththeinterventionduringthatsession.Acrossatleastfivesessions,theprogramshutdownandrequiredthe interventionist to reset the app and pagethroughtheappuntil thestudentwasbacktothelocationwheretheyhadbeenworking.Fourth,itisvaluabletonotethattwoofthreestudentsdemon-strated an effective intervention based on PNDwhile the third demonstrated an ineffectiveintervention PND (Scruggs & Mastropieri, 2001).However, it is also noted that there are concernsovertheuseofPNDstomeasureeffectsizeinsinglesubject design (Olive & Franco, 2008) and overallthethirdstudentdidhavea7.5%change inmeanfrombaselinetointervention.Therefore,theresultsofthispilotstudyserveasafirststep inregardtoavailable supports foropinionwriting for studentswithmoderateandsevere intellectualdisability.Afifth limitation was the use of a nonstandardizedsocial validity measure. Although it is common insinglesubjectresearchtousearesearcher-createdmeasure,astandardizedmeasurewouldhavebeenstronger. Finally, the small numberof participantslimit thegeneralizabilityof findings. In contrast totheselimitations,whenconsideredwiththelitera-ture base on opinion writing for students withmoderate and severe intellectual disability, thecurrentstudyaddstotheoverallevidenceforusingthismethodwiththispopulation.In summary, we evaluated the efficacy of aninnovative TAI package for improving writtenexpressionforstudentswithmoderateandsevereintellectualdisability.Thecurrentbodyofliteratureinthisareaprovideslittleguidanceforteachingstu-dents with moderate and severe intellectualdisability to perform complex writing tasks. Evenless guidance is availableonhow to embed thosetasksintoongoingacademicinstruction.Wesoughtto address these issues by developing aninterventionpackagealignedwithgrade-levelskills,compatiblewithongoinginstructioninthegeneraleducationcurriculum.Wefeelthisstudyservesasapilotstudythatcanbeusedtoguideotherworkinthisarea.Thedevelopmentofwrittencommunica-tioniscriticaltothesuccessofallstudentsandhas

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vast implications across every aspectof one’s life.Therefore, it isessential that researcherscontinueto investigatenewandeffectivewriting strategiesthat can be implemented inways that reflect theubiquitous nature of written expression in thenaturalworld.

DeclarationsThis content is solely the responsibility of the au-thorsanddoesnotnecessarilyrepresenttheofficialviews of ATIA. The authors disclosed financialrelationships with the Department of Education,Institute of Education Sciences, and AttainmentCompany. No non-financial disclosures were re-portedbytheauthorsofthispaper.

AcknowledgmentsSupport for the research referenced within thisarticlewasprovidedbyseveralgrantsandcontractsincluding, inpart,byContractED-IES-14-C-0018ofthe U.S. Department of Education, Institute ofEducation Sciences, awarded to The AttainmentCompany. The opinions expressed do notnecessarily reflect the position or policy of theDepartment of Education, and no officialendorsementshouldbeinferred.

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Jones,K.,Hall,M.,&Jones,M.(2010).Whatdoes“collegeandcareerready”meanforstudentswithsignificantcognitivedisabilities?Lexington,KY:UniversityofKentucky.Retrievedfromhttp://www.naacpartners.org/publications/CareerCollegeReadiness.pdf

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AssistiveTechnologyOutcomesandBenefitsVolume11,Summer2017,pp.47-57CopyrightATIA2017ISSN1938-7261Availableonline:www.atia.org/atob

TechnologyBenefitstoElderlywithInfirmitiesinFunctionalMaintenancePrograms

RichardD.Steele,PhDChiefScientist,LingraphicaLisaHaynes,MS,CCC-SLP

ManagerofClinicalAffairs,LingraphicaLelandWheeler,MCCCC-SLP

RegionalClinicalDirector,HallmarkRehabilitationServices

Abstract

Wereportanoutcomestudyinvolvingeightat-riskresidents in long-term care facilities across fourstates. Residents were assessed in spoken andexpressive language, memory, mental status, andmoodbeforeandafter implementationofaFunc-tionalMaintenanceProgramthatincorporatedon-lineinteractivetools.Dataanalysesrevealsmallbutmeaningful improvements in expressive languageandinmemory,trendingtowardssignificance.Theyalso show these non-robust participants’ meanscoresformoodandmentalstatusremainedstable.Findingsarediscussedinthecontextofstakehold-ers’considerations, includingimprovingoutcomes,conforming operations, securing revenues, andsatisfyingparticipants.

Keywords: improved outcomes, on-line technolo-gies, functional maintenance programs, long-termcare

Introduction

TheUnitedStateshasanagingpopulation.AlthoughlifeexpectancyforU.S.citizenshasgrownsteadily

sincethenation’sfounding,therateofincreaseofadultsover65–asapercentageofoverallpopula-tion– is currentlyata recordhigh,circa 0.3%peryear.Moreover, it isprojectedtoremaintherefortwo decades. In consequence, older adults, whonow comprise about 14% of the U.S. populationoverall,will, by 2040, grow to roughly 20%of thepopulation,whichitselfwillhaveincreasedby19%intheinterim(U.S.CensusBureau,2014).Inshort,theUnitedStatesof thefuturewillcontainrecordhighnumbersofelderlycitizens.

As people age, vitality declines. Effects of declinemay appear rapidly or slowly, evenly or unevenly,pathologicallyornaturally;butover time theyareinevitable and ubiquitous, diminishing physical,cognitive, sensory, and other powers. The veryrangeofproblemsoftenresultsincomplexinterac-tions between co-occurring health issues that cangreatlycomplicateservicedeliveryforpositiveout-comes(Kaneetal.,2005).Effectivemaintenanceofhealth in these circumstances assumes great im-portance(WHO,2001;Haak,2002;OHTA,2008).Foritsgeriatriccitizens,theUnitedStateshasastakeinidentifyingimprovedmethodstoexercise,maintain,strengthen, and even augment functional abilities

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acrosssettings.

Arrangements to provide needed supports andinterventionsforelderlypersonswithinfirmitieslieattheheartoflong-termcare(LTC).Theterm‘long-term’reflectsthefactthatagingprocessesremainirreversible, and that provision of such care, oncestarted, is likely toremain in forcethroughendoflife. The delivery of LTC is rationalized along acontinuum.Whereminimal assistance is required,HomeHealthdeliversservicesinplacetoclientsliv-ing in their own houses or apartments semi-independently.SupportedLivingCommunitiesservethosewhorequiremoreassistance,withrecipientsliving in clustered home-like accommodationsprovidingaccesstocommunaldiningfacilities,orga-nized resident activities, and other beneficialservices.SkilledNursingFacilities(SNFs)areresiden-tial facilities serving thosewho require yet higherlevels of daily assistance in common Activities ofDailyLiving(ADLs)suchastransfer,bathing,dress-ing,grooming,andalsoInstrumentalADLs(I-ADLs),such as telephoning, doing laundry, and takingtransport. Finally, Hospice provides all necessaryend-of-lifecareforthosewithterminalconditions.Some people move systematically along thiscontinuum, as health conditions change and sup-port needsmount (Harris-Kojetin, Sengupta, Park-Leeetal.,2016).

OrganizationsthatprovideLTCmayfocusonasingletieralong thecontinuum,or theymayencompassmultiplelevelsandbeverticallyintegrated.Ineitherscenario, they must focus on key businessconsiderations, including securing revenues,conforming operations (e.g., assuring compliance,standardizing operations, etc.), improving healthcare outcomes, and strengthening satisfaction. Allare important; but in practice, not equally.Revenuesareforemost,asbusinessesmustremainprofitabletostayopen;theotherfactors–improv-ingoutcomes,conformingoperations,andincreas-ing satisfaction – will be balanced in conjunctionwiththeirassociatedrevenueconsiderations.

Technological innovations to improve delivery of

services toelderlywith infirmitiesand lowercostsareinprinciplealwaysofinterestinLTCoperations.Inthispaper,wereportastudyconductedbytwocompanies – Hallmark Rehabilitation Services andLingraphica® – that examined the effects ofintroducing on-line and technologically advancedinteractive language exercise tools into existingoperations that employ a FunctionalMaintenanceProgram(FMP)inLTCfacilities.

TargetAudienceandRelevance

Thisworkisofrelevancetoindividualsandinstitu-tionsinvolvedingeriatrichealthcare,especiallyLTCfacilities,associatedreimbursementagencies,assis-tive technology providers, LTC residents’ familymembers,otherfriends,andvolunteers.Theprojectwasinitiatedwiththreerelatedobjectives:[i]toex-plorewhatisinvolved,practically,inintroducingon-line,interactivespeechandlanguageexercisesintoongoingLTCoperations; [ii] todeterminehowthetechnology can enrich FMPs for non-robust resi-dents within such facilities (Haynes & Wheeler,2015a,b);and[iii]toidentifytheoutcomebenefitsto stakeholders involved. In this project,HallmarkRehabilitation serves as an example of a contractrehabilitationcompanythatprovidesskilledperson-nelandservicestoSNFs;andLingraphicaservesasanexampleofcompaniesthatdevelopofferingsforpersonswithcognitiveandcommunicationdeficits(Lingraphica,2016).

StudyMethods

Design

The investigatorsdesigneda study thatwoulden-gage staff, residents, andothers inSkilledNursingFacilities while minimizing disruption to on-goingoperations. Formally, it is an outcome study inwhich pre- and post-intervention data come fromtwo complementary sources: (i) theNationalOut-comes Measurement System (NOMS), from theAmerican Speech-Language-Hearing Association(ASHA,2003);and(ii)MinimumDataSetmeasures(MDS), published in the Residential Assessment

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Instrument (RAI, 2015a, b). By design, the studyincorporatedon-line,interactivelanguageexercisesinto individualized FMPs.While the expertise of acredentialedclinicianisrequiredtosetupFMPs,thefollowing implementation may be handed off tocareextenderssuchcommunityvolunteers, familymembers, or activities facilitators (ASHA, 2004).Theselattergenerateeitherlowercostsornocostsat all to LTC facilities, whichmakes this approachattractivetofacilitiesfromarevenuestandpoint.Inthisstudy,durationof technologyusebyLTCresi-dentswas permitted to vary according to circum-stancesoffacilitiesandparticipants.

Participants

ThefourparticipatingSNFs–threeintheMidwestandoneintheWest–wereselectedbythisarticle’sthird author, Leland Wheeler, Director of ClinicalServicesatHallmarkRehabilitationServices(Haynes&Wheeler, 2015a).At each facility, two residentswereenrolled inthestudy,yieldingatotalsamplesizeof8.Localstaffateachofthesitesselectedtheparticipants, who were all non-robust. They werechosenonthebasisofrecentdeclinesinscoresonMDSappraisals,thepresenceofdiagnosticriskfac-tors such as cerebrovascular insult or progressiveneurodegenerativeconditions,andnursingreferrals

indicating intervention initiation. Those combinedfactorssuggestedtheseresidentswereatelevatedriskforsocialandorcommunicativeisolationabsentintervention, such as an FMP. Such cases arechallenging and usually involve complex interac-tions between cognitive, sensory, physical, andhealth management issues (Kane et al., 2005;Kociuba,Davidson,&Doninger,2014).Table1givesdetailonthesesubjects,locations,conditions,areasofparticularconcern,andlengthofparticipationinthis study. Inspection shows they comprise aheterogeneous group with regard to diagnoses,deficits,issues,andgoals.

Interventions

AsStep1,theclinicalSLPsatthefacilitiesusedon-line therapy exercises that focused on fourcommunication modalities – listening, speaking,reading,writing–toestablishparticipants’baselineperformance with these tools and materials. Theprogram used was TalkPath Therapy, an offeringthatLingraphicamakesavailabletoall,atnocharge,aseitheranappdownloadedontoaniPad,orasaweb-basedserviceaccessedviaabrowseronacom-puter (TalkPath, 2016). The SLPs then initiatedindividualizedtreatmentsessionswithparticipants,withthedualgoalsofreducingcommunicativeand

Table1Participants

I.D. State Diagnosis FMPFoci FMPWksPD KS Dementia,depression Functionalexpression 13.0DR KS Dementia,depression Auditorycomprehension,verbal

expression13.0

RS TX Dementia,depression Memory,comprehension 12.0BH TX Hypertension,Intellectual

disabilityNaming,expression [missing

datum]JD CA Dementia,alteredmental

statusSocialcommunication,Problem-solving

8.7

LS CA Aphasia,chronic Automaticspeech,naming 4.4DD MO Dementia,alteredmetalstatus Problemsolving,orientation 13.0CW MO Alteredmentalstatuspost-CVA Orientation,reading,

comprehension6.0

Mean(SD) 10.0(3.7)

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cognitive deficits, while concurrently trainingparticipantsintheuseofthetechnology.Owingtothe complex patient sample – many participants’diagnoses included dementia, past CVA, mentalstatus change, depression and/or anxiety –individualizedtherapygoalsweredisparate.Fociin-cluded, for example, responsive naming, problemsolving,memory,andreadingcomprehension.

When participants demonstrated adequateproficiency in using the technology, SLP activitiesmoved to Step2 – the transition to individualizedFMPsfortheeightparticipants,inaccordancewithASHA-specifiedproceduresforFMPs(ASHA,2004).Once in place, FMPs may be carried out by careextenders such as family members, activitymanagers, or volunteers, after basic technologytraining. Importantly, there is no therapeuticdimension to an FMP. The core purpose is not topromote additional improvements over time, butrathertoengagerecipientsinactivitiesdesignedtohelpmaintainmentalsharpnessandstaveofffunc-tionaldeclinesthatotherwisethreatentooccur.

TechnologyTraining

Training took place on laptop computers. Eachparticipanthadhisorherownaccountsetuptoac-cessandusethelanguageexercises,whichcouldbeadjustedbythesupervisingSLPclinician.TheSLP,inturn,hadastimulus-responsetooltouseintherapy,a client management system, and data collectionand reporting capabilities. The treating therapistusedTalkPathTherapytaskstoestablishabaselineintheareasoflistening,speaking,reading,andwrit-ing,andconcurrentlytoconsiderselectionoftools,materials,andmethodstobeincorporatedintotheFMPthatfollowed.Thecareextendercouldobservethis initial treatment phase as well, to becomefamiliarizedwiththeprogramandconsideritsusesinthesubsequentFMPimplementationphase.

Assessments

Outcome measures. Data for the OutcomeMeasures (OM) came from three domains of the

Adult Functional Communication Measure in theASHA NOMS, namely: (i) Spoken LanguageComprehension; (ii) Spoken Language Expression;and (iii) Memory. Staff speech-languagepathologists rated participants using the scaledeveloped by ASHA, which assigns scores rangingfrom0(MostImpaired)to7(NormalFunctioning).The initial ratings were done immediately beforeStep1oftheTalkPathintervention,andthefinalrat-ingsweredoneuponcompletionofactivityinStep2,theFMPprogram.

Quality measures. We employed two QualityMeasure (QM) tools whose results are recordedquarterlyintheMDSkeptroutinelyonresidentsinLTCfacilitiesthroughouttheUnitedStates,namely:(i)BriefInterviewforMentalStatus(BIMS);and(ii)ResidentialMoodInterview(MOOD).BIMSprovidesvaluable data for monitoring residents’ attention,orientation, and ability to register and recall newinformation. MOOD screens for symptoms ofdepressionandgeneratesaclinicallyusefulseverityscore.

DataAnalysis

Raw scores were entered into Microsoft Excel v.14.0.0runningonanAppleMacBookrunningMacOS X ver. 10.6.8 for completing statistical calcula-tions. To investigate changesover time,we calcu-lated score means before and after intervention,and used parametric statistics to determine theexistence,direction, andmagnitudeofdifferencesformeansatthetwopointsintime,andtoestablishthestatisticalsignificanceofthosedifferencesusingmatched t-tests (Hatch & Farhady, 1982; Frattali,1998). These procedureswere used to analyze allpre- and post-interventions data (i.e., NOMSExpression, Comprehension, Memory, BIMS,MOOD).

OutcomesandBenefits

FromASHANOMSTable2showschangesinNOMSoutcomemeasuresatthecompletionofFMPactivity.

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All three NOMS items showed mean positiveimprovementsfollowingtheinterventionperiodofthisstudy.Thesmallestchangeisincomprehension:ontheseven-pointscaleemployedbytheNOMS,itshowed a statistically non-significant outcomeimprovementof+0.29points (p= .229).Bothpre-and post-comprehension scores registered at theNOMS rating level of 4 (4.14 –> 4.43), a levelimmediatelybelowthatofautonomous functionalindependence. Overall, spoken languagecomprehensionmustbeconsideredeffectivelyun-changed following intervention. The remaining 2NOMSitems–expressionandmemory–changedinmore complex ways. Specifically: [i] both theirmeans improved by +0.57 points; [ii] the decimalcharacteristicsforbothmoveduptothenexthigherNOMS performance level (i.e. 3 –> 4 and 1 –> 2respectively);and,[iii]bothoutcomeimprovementstrended towards statistical significance (p = .086).Given the quantitatively comparable and statisti-callysignificantNOMSexpressionimprovement(∆=+0.60,p=.006)inanearlieroutcomestudythatrantwoweekslonger,enrolledoneadditionalsubject,and engaged SLPs rather than volunteers toworkwithsubjects(Steele,Baird,McCalletal.,2014),onemight imagine a larger sample size and/or longerintervention period producing improvements ofstatistical significance. Follow-on research shouldthusincludeattentiontothisissue,amongothers.It isworthrecallingherethatthisstudy’sactivitiescomprisetwodistinct,complementaryphases:(i)aninitial, relatively short phase of therapy conjoinedwithtrainingonthetechnology;followedby(ii)thelongerperiodofFMPactivity,carriedoutbythecareextender using the tools, materials, and methodsthathadbesetinplaceforthepurposebytheSLP

before stepping back. Improvements documentedhere broadly parallel improvements found frompreviouscomparabletherapyresearch(Aftonomos,Steele,&Wertz, 1997; Aftonomos, Appelbaum,&Steele,1999;Aftonomos,Appelbaum,Steeleetal.,2001; Steele, Aftonomos, & Munk, 2003; Steele,Aftonomos,& Koul, 2010; Steele, Baird,McCall etal.,2014;DesRoches,Balachandran,Ascensoetal.,2015). Itwouldbeof value, in future research, toadministeradditionalassessments, for instance,atthe transition from Step 1 to Step 2, in order tocharacterize time courses of improvement vs.maintenance. Various longitudinal profiles areimaginable.Thecurrentstudydesigndidnotgener-atethedatathatshedslightonthismatter,butitisofpotential importanceandshouldbetargeted infutureresearch.From the Residential Assessment Instruments’MinimumDataSetMental status. Figure 1 shows the Mental Statusratings of the 8 participants at the beginning andend of the calendar quarter containingmost FMPactivity.In themean,overallBIMSscores remainedsteadyduring this quarter. Although scores of 5 of the 8participantswenteitherupordown,themeanscoreattheendofthatquarter,6.63,wasidenticaltothe6.63mean score at the beginning of the quarter;anditplacestheparticipantsinthisstudy,generally,withintherangeofseverecognitiveimpairment.In-deed,visualinspectionshowsthat6ofthe8partici-pantsreceivedatleastoneratingof7orbelow,theboundary for severe cognitive impairment. Thisclearlywasagroupwithchallengingcognitive

Table2ChangesfollowingPeriodofTechnologicalIntervention

Item N Pre-(SD) Post-(SD) ∆ pAuditoryComprehension 7 4.14(0.69) 4.43(0.98) +0.29 0.229Expression˚ 7 3.43(0.79) 4.00(1.53) +0.57 0.086Memory˚ 7 1.86(1.07) 2.43(1.51) +0.57 0.086˚p<.10(=trendtowardsstatisticalsignificance)

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issues;andsome individual changeswerestriking.Participant PD improved from moderate impair-ment range to the cognitively intact range, andparticipantJDimprovedfromsevereimpairmenttomoderate impairment; in contrast, participant RDdeclinedcognitively frommoderate impairment tosevere impairment. The result was mean overallstability in BIMS scores in the presence ofconsiderable individual variability. To understandhowcommonapatternthisis,anditsimplications,

futurestudieswillberequired.Mood. Figure 2 shows theMood ratings of the 8participants at the beginning and the end of thequarterofmostFMPactivity.Mean overall MOOD scores changed only slightlyduring thequarterduringwhich the studyactivitytook place. The mean score at the start of thequarterwas1.63,indicatingminimaldepression;by

Figure1MentalStatus,atBeginning&EndofQuarter

Figure2

Mood,atBeginningandEndofQuarter

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theendof thequarter, ithad increasedto2.13,anon-significant change (p = 0.16) occurring aboutmidwaywithintheminimaldepressionrange.Thiswasalargelynon-depressedgroupthatstayedthatway over the period of FMP activity. The largestmovementwasinparticipantPD,whosescorerosefrom6–towardsthelowendofmilddepression–to9–indicatingthemilddepressionhadintensifiedsomewhat. Of note, PD was also the participantwhoseBIMSstatusmovedto‘cognitivelyintact’byquarter’send;raisingthepossibilityofherincreasedlucidityperhapsresultedinagreaterawarenessofher surroundings and circumstances, potentiallycausing the observed intensification within milddepression.

Itshouldbenotedthatonlylong-termdatacollec-tionandanalysiswillrevealthedominantpatternsforMDSdata thatwillultimatelybeof interest toLTC facilities. These statistical MDS findingsrepresent acceptance of the Null Hypothesis, i.e.,thatthereisnosignificantdifferencebetweenmeanpre- and post- assessments. And indeed, MDSstability longitudinally will present precisely asperiodically repeated absence of statisticallysignificantdifferences.Onlycollectionandanalysesofdataonlargerscalesandoverlongerperiodswillallowustoidentifytheprofilepropertiesofstabilitypatterns, while flagging aberrant cases for closerscrutiny.

SatisfactionFeedback

Rather than develop a formal survey to probeparticipants’ satisfaction for this initial study, theinvestigators drew on post-investigation observa-tions from the third author, LelandWheeler,whowasManagerofClinicalServicesattheparticipatingsites. He retrospectively discussed what he heardfromhissubordinatesonsiteduringconductofthestudy,andthefullinterviewisavailableforauditiononline.Weincludequotesbelowfromthatsource.

Lelandreportsthatincorporationofthetechnologyresulted in improved follow-through in the Func-tionalMaintenancePrograms, inpartbecause the

technologywas found to be attractively simple tolearnandeasy touse.Akeypractical stepwas todesignate an appropriate individual as ‘champion’for the FMP at each site, who could come fromdisparate domains: at some facilities, restorativenursing staff supplied them; in others – activitiesstaff;andinyetothers–familymembersorspeechpathology students. The important thingwas thatonce the FMPhad been set upwith goals, proce-dures,andthecustomizedtechnologies,anyinter-ested person could – following initial training –implementtheprograminpractice.Onrateofadop-tion,Lelandsays,“Onceweestablishedwhothesekey players were going to be, the program reallystarted to take a life of its own. We had a fewpatients really thrive with it just because of theencounters theywere able to get one that skilledtherapyhad[…]transitionedover[…]tothatrepeti-tive stimulation program.” On acceptance byclinicians:“Theyadapted to itverywell,andwerereallyasking‘CanIdothiswithmorepatients?’”Andregarding adoption of the technology by all in-volved,“Theyreallyadaptedtoitextremelyquickly.They liked that itwasaccessible, they liked that itwasondifferentplatforms,and…theyhadfunbe-cause it wasn’t what they were used to doing”(Haynes&Wheeler,2015c).Whileanecdotal,thesecomments do point to certain broad themes –empowerment of non-clinicians, convenience ofprogram structuring, and enjoyment of novelinteractions– thatmerit closer study in future re-search.

Discussion

This studyprovides initialdocumentation that LTCresidentsofprecarioushealthstatuscanbenefitinimportantwaysfromstrategicallyintegratedonlineinteractivetoolsthatexercisespeechandlanguagewithin a Functional Maintenance Program. TheinvestigationwasconductedinLTCsettingsinfourstates, following a design that accords with theclinical concerns, usual practices, operational con-straints,andpatientcohortsofsuchfacilitiesingen-eral. Study subjects were chosen locally, fromamongcurrentSNFresidents,andwereselectedon

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the basis of recent declines in health status,diagnoses that raised red flags, and rehabilitationnursingreferrals.OfpracticalimportancetohostingLTC facilities operationally, no alterations to staff,administrativeworkloads,orreimbursementproce-dureswererequiredtoconductthework.

Inthisinitialinvestigationofmodestscopeandbriefduration, positive outcomes were documented inboth the formally designated NOMS OutcomeMeasures (OM)of thestudy,aswellas inthe lesstightlyassociatedMDSQualityMeasures (QM) formentalstatusandmoodthatarecollectedquarterlyon all residents in such settings for Medicarereimbursementpurposes.OntheOMs,theLTCresi-dentsshowedoutcomeimprovementsattheendofFMPactivitywithtrendstowardsstatisticalsignifi-canceintwoofthosethreedomains,namely,oralexpressionandmemory.Ineachoftheselattertwo,meanimprovementsweresufficienttoadvancethegroupasawholetoaqualitativelyhigherfunction-ing level on final assessment: in spoken languageexpression, the groupmoved to the highest leveljust below independent functioning; and inmemory, thegroupasawholemoved frombeingunabletorecallanythingtobeingabletorecallper-sonal information with requisite structuring andcueing.Thethirddomain–auditorycomprehension– waseffectivelyunchanged.On theQMs,partici-pantsappearedtobeessentiallystable,withmentalstatus showing no mean change whatever, andmoodregisteringonlyasmallmeandeclinethatwaswithout statistical significance. This relative QMstability,viewedinlightoftheseparticipants’deficitetiologies and recent negative status changes,represents the desired finding. It suggests theinterventionmaycontribute toQMstatusmainte-nanceinsuchLTCresidents.

Use of technological tools in a FunctionalMainte-nance Program, then, appears to hold promise intheLTCdomain.Suchanapproachrepresentsanim-portant opportunity for staff clinicians who havebeen providing clinically therapeutic interventionsthat are drawing to an end. Reimbursement fortherapyisdiscontinuedwhenclientgainstaperoff,

atwhichpointSLPsbenefitfromhavingatransitionoptionsuchasanFMP.TheSLPscanbereimbursedforsettinguptheFMP,andthe lattercanthenbehandedofftolessexpensivecareextenders–staff,family, or volunteers – for implementation. Onceunderway, SLPs’ re-involvement isnot requiredaslongasrecipients’functionallevelsaremaintained.Thecareextendersbenefitaswell:familymembersorfriendsofLTCresidentsmaybepersonallymoti-vatedtosharetimewiththelatter,andtheycravetoolsthathelptheminteractenjoyablyandbenefi-cially.LTCactivitymanagerswantactivitiesthaten-gageenthusiasms,promotesocialinteractions,andhelp residents avert MDS declines. Communityvolunteers benefit from tools that are clear, easyandenjoyabletouse,andengagingincontent.

LTCfacilitiesrealizebenefitsaswell.TheirstaffSLPscapture reimbursement for the skilled services ofproviding the technology training and associatedtherapy required to setupanFMP.Subsequently,facilityeconomiesarerealizedwhentheFMPactivi-ties carried out by care extenders who typicallywork for less or are volunteers. The ability of thetreatment technologies to capture use data onservers for subsequent review extends availablemeans of monitoring and managing compliance,and otherwise conforming operations. And thepreliminary positive comments of participants re-ported above suggest user satisfaction levels thatcould support prolonged effective use. Conse-quently,meansforenhancingrevenues,conformingoperations(e.g.,documentingcompliance),improv-ingclinicaloutcomes,and leveragingusersatisfac-tionhaveallbeenpreliminarilyprobedinthisinitialstudy.

Thestudyalsosuggests futurework.Wenote, forinstance, that participants’ mean Memory scoresimproved despite the absence in this study ofmodules that target Memory explicitly: moduleshereaddressedsolelylanguagemodalitiesoflisten-ing,speaking,reading,andwriting.Thisfindingsug-gestspotentialadditionalbenefitfromthedevelop-mentandinclusionofmaterialsexplicitlydesignedto exercise and strengthen memory functioning.

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Opportunitiesalsoexist todevelopcapabilities fortracking and reporting user engagement andsuccesslevelsinreportableforms.Clinicalsupervi-sorswithinfacilities,forexample,inprinciplecouldreview summary reports of who has been usingwhichmodules,forhowlong,withwhom,andwithwhat frequencies. In the same vein, summary re-ports of overall use patterns by facility types, bygeographical region, by patient census variations,andthelikecouldbevaluableforofficersathigherlevels of responsibility within geographicallydistributed networks of facilities. Such capabilitiescan effectively be used to establish benchmarks,identify best practices, and support continuousquality improvement within such clinical opera-tions.

The research here is preliminary, and conclusionswillundoubtedlybesubjecttorefinementafterfur-ther research. The investigators acknowledge inparticularthelimitationsassociatedwiththestudy’ssmallsamplesize.Withfewparticipants, interven-tioneffectsneedtobebothrelativelylargeandrela-tively consistent to achieve statistical significance.Thismaywellaccountforthefindingoftrends to-wards–withoutactualachievementof–statisticalsignificanceintwoofthethreeoutcomesmeasures(NOMS expression andmemory). Future researchshouldinvolvelargersamplesizestoestablish–withgreatercertainty–theloci,themagnitudes,andthelikelihoods of therapeutic benefits to those whoparticipateinthisapproach.

Outcomestudiesalsohaveintrinsiclimitationsthatrequiremention.Foronething,theydonotpermittheattributionofcausality.Thisisbecausetheydonotcontainacontrolgroupagainstwhichtocom-pare changemagnitudes and directions. Causalityattribution requires a different design, that of ascientifically controlled prospective experimentalstudy. To understand the specific contribution oftheinteractivetechnologiestotheoutcomesdocu-mentedhere,then,wouldrequiresuchafollow-oncontrolledstudy.Foranotherthing,outcomestud-iesconductedwithinongoingclinicaloperationswillinvariably reflect somesortof samplebias. This is

becausethestudyparticipantswillnotrepresentarandomizedsampleofpeopleinLTCsettings,butra-ther,somespecificallyselectedgroup–here,forin-stance,thoseLTCresidentswhowereidentifiedasvulnerable to declines in QM measures, yet whowerewilling to participate in the initiative. Again,the work points directions for further targetedresearch.

Preliminaryas it is, thisstudynonethelessdemon-strates the feasibility and acceptability of theapproach generally. Participants in LTC facilitiesbroadlyembracedthetechnology,whichwasfoundtobebothusableandenjoyable.Itsintroductiondidnotturnouttobeproblematicorburdensome.Itsuse engaged the attention and enthusiasm ofparticipants in ways that promoted the FMP’seffectiveness.Participatingresidentsinthefacilitiesarguably benefited from the experience in im-portantways.Suchfindingsprovidetheencourage-mentforfollow-onresearch,development,andpro-gramelaboration.

Toconclude,withagrowingsegmentoftheAmeri-canpopulationmovingintooldage,andprojectionsof record numbers of elderly citizens in two dec-ades,itisimportanttoprepareadequatelytomeetthe challenges they will pose. Not all seniors willmove into LTC settings, but many will. ImprovingLTCoperationstoyieldmorecoherentandeffectiveservice delivery, improved outcomes, highersatisfactionlevels,andloweredcostsisimperative.Properlydevelopedandutilizedtechnologyappearsto be well positioned to contribute in importantwaystoachievingthoseresults.

Declarations

This content is solely the responsibility of theauthors and does not necessarily represent theofficial views of ATIA. The authors disclosedfinancial relationships with Lingraphica andHallmark Rehabilitation Services. No non-financialdisclosures were reported by the authors of thispaper.

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CommunicationandDevelopingRelationshipsforPeopleWhoUseAugmentativeandAlternativeCommunication

ChrisKleinBeComeAAC

Abstract

Buildingmeaningfulrelationshipsisoneofthemostimportantthingsapersoncandoinhisorherlife-time.Italsoisoneofthemostdifficultthingsaper-soncando.Communication isanecessity tobuildrelationships, so a person with a communicationdisabilityhasaverydifficulttimebuildingrelation-ships.Therearevariouspublicationsthatarecallingforrelationshipbuildinginthefieldofaugmentativeandalternativecommunication(AAC).AsapersonwhohasusedAACforover36years,Ihaveexperi-encedthisfirsthandandfeelthisisadiscussionthatgetsforgottenaboutalltoooften.Italsoisadiscus-sion ledby clinicians, professors, andmanufactur-ers. This is why I feel it is important to give myperspectiveonthistopic.

Keywords: consumer perspective, AAC,communication,buildingrelationships

Introduction

Todayinaugmentativeandalternativecommunica-tion (AAC), we see folks with a wide range ofcommunication disabilities. Some, likeme,mostlyhave physical limitations. Many have cognitiveissuesaswell.Peoplewithautisticspectrumdisor-ders may not understand that interpersonalcommunication can be one of themost enriching

aspectsoflife.Nevertheless,manypeoplethatuseAACarenotdifferentfromtherestofsociety.Theywanttobuildandmaintainrelationships.However,lackofcommunicationoftentimesbecomesamajorbarriertobuildingrelationships.Weare living inafast-pacedsocietywherepeopleseemtohavelittletime to stop and have a genuine conversation.Theseconversationsstillhappenonoccasion,butittakesefforttogetpeopletostopandtrulyengagein a conversation. I have seenpeople sayhello tosomebodyandwalkawaybeforeevengettingare-sponsefromthepersontheyjustsaidhelloto.Peo-ple seem to want the person to respond that in-stant,sothattheycangoontheirway.Thisiswhyoftentimespeoplewithcommunicationdisabilitieshave a difficult time getting into a conversation.Whenapersoncan’teffectivelycommunicate,heorshehas limitedopportunities to interactwithoth-ers.

DifferingCommunicationGoals

Participation inschooloftenbecomesthefocusofthe teacher, family, and speech-languagepathologist.Participationinclassbyansweringspe-cificquestionslike“Whatdowecalltheprocessofcelldivision?”(Mitosis)canbepartofacademiclifefor an augmented communicator. However,answering such questions regularly puts a burdenon teachers, therapists, and family members to

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supplysuch“homeworkwords”onaweeklyorevendailybasis.Suchactivityalsotendstoreplacelearn-ing how to communicate as an interesting personwithone’sclassmates,family,andfriends.

Inmyexperience,socialisolationisacommonfac-tor forpeoplewhouseaugmentativeandalterna-tive communication. PeoplewhouseAAC tend tohavelimitedaccesstocommon,everydaylanguage,whichpreventsthemfrombuildingrelationships.Itisn’tenoughtogiveapersonanAACdeviceif it ispre-programmedwithphrasesandsentences.As Ihavediscussedamongmypeers,wewanttohavetheabilitytosayanythingwewanttosayasquicklyaspossible.Whenweareabletoshareanything,weareabletosharetheintimatestrugglesthatarego-ing on in our lives. Sharing these struggles andconsolingoneanotherishowlonglastingrelation-shipsarebuilt.ThisiswhyitissoimportantanAACdevice gives them the proper access to everydaylanguage. People who use AAC need access to atleast150corewords,sothattheycanstarttolearnhowtodevelopsentences.

A primary responsibility of a speech-languagepathologist working with a person with acommunicationdisabilityistoadvocateforandpro-motetheuseofAACsystemsthatallowthepersontocommunicatetotheirbestoftheirabilities.How-ever,thequestionthenbecomes,“Wheredowegofromhere?”WehavesomanydifferentinfluencesthatdecidethisdirectionthatwelosesightofwhatisimportanttothepersonwhoisgoingtobeusingtheAACdevice.

Thisiswheretheinfluencesordecisionsbecomethedictator.Theybecometheendgoalandallofasud-dencommunicationbecomessomethingdifferent.Itdoesn’tbecomeabouthisorher languageabili-ties; it becomes about meeting the educationalstandardsorsimplyusingimportantfeaturesofthedevice.

But,areweexpectingpeoplewithcommunicationdisabilities to grow their language skills? Are weexpecting them to be able to build relationships?

Parents, teachers, and speech-languagepathologists are faced with these two questions.However, the educational standards usually takeprecedenceoveranyotherskills.Bydoingthis,wearen’tgivingthestudentthetoolstocommunicateeffectivelyenoughtobuildontheirlanguageskills.

I acknowledge some people with a complexcommunication disability have a language barrierthatalsohamperstheirlanguagedevelopment.Thiscanmakeassessing their language skills verydiffi-cult. However, if a speech-language pathologistdoesn’tgivethemaccesstoeveryday languageontheir device, assessing their language skill ismoredifficult.

I amspeaking frompersonalexperiencebecause IwasbornwithcerebralpalsyandIhaveacomplexcommunicationdisability.Irememberhowfrustrat-ing it was trying to express myself without beingabletojustsaythewordsIwantedtosay.IfeltlikeI was trapped inside myself, and this feeling isoverwhelming. I understood everything that washappeningaroundme,butIcouldn’tshowanybodybecauseIdidn’thaveaccesstoeverydaylanguage.

FrameworkforConsideringGoalsandImprovingCommunication

The question becomes “What are the tools ofcommunication?”JaniceLightdefinesadequacyofcommunicationasanadequatelevelofcommunica-tionskill tofunctionwithinacertainenvironment.Shestates itdoesnot implyatotalmasteryoftheartofcommunication(Light,1989).Ibelievethisisagooddefinitionofadequatecommunication.Lightgives us four competencies underlying this defini-tion of adequate communication. These fourcompetenciesarelinguistic,operational,social,andstrategic.Shebreaksdowntheseintotwosections.Thefirstsectionislabeledastheknowledgeandskillintooluse,whichincludesthelinguisticandopera-tionalcompetencies.Thesecondsectionis labeledbyLightasthefunctionalknowledgeandjudgmentininteraction,whichincludesthesocialandstrate-giccomponents.Let’s takea lookateachofthese

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competencies.

LinguisticCompetence

Thelinguisticcompetency,inmyopinionasanAACuser, is crucial in developing progress incommunication. If you don’t have simultaneousaccess toabroad rangeof corewords, youaren’tgoingtobeabletocommunicateeffectivelyorde-velop adequate language. One of the most im-portant things to a person who uses AAC is tocommunicatetothebestoftheirabilities.Weneedthis linguisticcomponenttobethereonwhateverdeviceheorshedecidestouse.

JaniceLightbreaksthe linguisticcomponentdowninto two sections.ApersonwithAAChas tohavemastery of their native language. A person usingAACalsohastodevelopawaytoprogressthroughthe linguisticcode found inhisorherAACdevice.Thecentraltoolinachievingthesefourcompeten-cies,fortheAACuser,isautomaticprocessinginthemicro-skills (reading,writing, listening, and speak-ing) of languagemastery.Mastering language canbeviewedasautomaticprocessingconcerningwhatyouwant tosay,havingmotorplanswellmappedout for accessing your communication aid, andstrongfamiliaritywithcorevocabulary,coresyntax,coremorphology,andcorepragmatics.Inpractice,mastery of these skills can translate into an in-creasedrateofcommunication,whichiscriticaltosuccessful communication and relationship build-ing.

Communicationratebecameanimportantaspectofmylifeataveryyoungage.Itwasfrustratingformetryingtoplayaguessinggamewithmyfamily.Everytime Iwantedor needed something, the guessinggamebegan.Attimes,IbecamesofrustratedthatIwouldcurlupinaballandcry.Nobodycouldunder-standme,evenafterItriedtopointandgesturetotheobject that Iwantedorneeded. Formyself, itwasveryfrustrating,yetitwasevenmorefrustrat-ing for my communication partner. They didn'tknow what I needed or wanted, so they wereequally as frustrated. This is where my speech-

language pathologist gave us a picture board tosolvetheproblemofcommunication.Ithadpicturesofthebathroom,amom,adad,awaytosayIloveyou,Iwantadrink,andthosetypesofthings.Itdidsolvealittleofthefrustration,butIwasachildwhowanted to saymore than that. I had other thingsthatIwantedtosayandIcouldn'tdoitwithapic-tureboard.

Communicationwithapictureboardandgestureswasn't enough for me, but how would they everknow that. I couldn't exactly tell them what washappening inmymind, so I tried to communicatewithwhatIhadandwhatIknew.Itwasatsixyearsold that I received my first augmentativecommunicationdevice.Itwasaword-basedsystem,whichhad four levels ofwordson it.Also, on thefourthlevelofit,ithadthreerowsofphoneticlet-ters.Youcouldsoundoutanywordthatyouwantedtosay.ThesystemhereallowedmetosayanythingthatIwantedtosay.

OperationalCompetence

IwassenthomewiththatdeviceonaFriday,andbyFridaynight,Iwasalreadytalkingincompletesen-tenceswithit.Myspeech-languagepathologistgavemewords for the first time inmy life,and I couldfinallytellmyolderbrothersandsisterstoleavemealone.IcouldsaywhatIwantedtosayforthefirsttimeinmylife,andthatiswhyIuseditquickly.

Communication devices have been known to usepre-programmed sentences and words that arenounsmore.Inmyexperience,manypeoplebelievepeoplewhouseAACneedtoansweraquestioninclass, order food, tell somebody what they need,and those typesof things. Idon'tbelieve theyarelookingatthebiggerpicture.Acommunicationde-vicehastheopportunitytogiveapersonachancetodeveloplanguageskills.Bybeingabletodeveloplanguageskills,itgivesthepersonachancetobuildrelationships. Inorder for thatcommunicationde-vicetodothat,ithastogivethepersonthechancetosayanythinghewantstosay.

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The idea of a communication device is to haveconversations with people. In order to haveconversationswithpeople,thepersonneedsaccesstoeveryday languageonhisorherdevice.Thisal-lowsthepersontolearnlanguage,whilethepersonis learninghowtocommunicate. Itallowstheper-sontogothroughthestagesof languagedevelop-ment, which allows them to build upon theirvocabulary.Yet,themostimportantaspectisital-lowsthepersontobuildanddevelopthelonglast-ingrelationshipsthatwealldesire.

The device that my speech-language pathologistgavemehadeverydaylanguageonit.Iwasabletosay anything that I wanted to say. I could tellmybrothersandsisterstoleavemealoneforthefirsttime.My teacherswereable to seemebuild sen-tences, which showed them that they weren'tchallengingmeenough.Theywereable tocorrectmygrammarandsyntax,whichallowedmetogrowinmylanguageskills.

Thishelpedeverybodytoassessmylanguageskills.Iwasputinspecialeducation,butonceIwasabletoexpressmyselfproperly,theywereabletoseethatIneededtobechallenged.Iwasputintheregularclassroomstartinginthirdgrade.

The teachers taughtme like all of their other stu-dents,givingmeachancetoanswertheirdescrip-tivequestionsaboutasubject.Wehadawordofthedaycontest,whichwewouldhavetodefine.Who-ever defined it correctly first received a prize forthat day. This was to help build onto our ever-expandingvocabulary,butalsohelpusbuildourlan-guageskillsbyhavingusdescribetheword,insteadofjustnamingit.Thiswasthekeytomysuccessbe-cause if I didn’t have the same opportunities tolearn,Iwasgoingtobefarbehindmyclassmates.

I don’t remember ever programming homeworkwords into my device. My teachers asked medescriptive questions, such as “What isPhotosynthesis?”Iwasabletoanswer,“Itisthepro-cess of howplants use the sun and light tomakefood.” I was learning about what photosynthesis

was,butIlearnedhowtodescribeitwitheverydaylanguage.

It is importanttobuildontoaperson’svocabularywiththeseeducationalvocabularywords.However,wedon’thavetoprogramthesewordsintotheirde-vice. A person can describe thesewords by usingeverydaylanguage.Thisisbetterforhimorherbe-causetheparent,teacher,orstudentaidecancor-rectsyntaxandgrammar.Thisishowthepersonisgoingtobuildonhisorherlanguageskillsandthus,becomeamoreeffectiveandefficientcommunica-tor.

SocialCompetence

Whiletheeducationalsideofthingsisimportanttoconcentrateon,thesocialaspectoflifeisjustasim-portant.Ifyouthinkaboutit,wearedesignedtobesocial.Itisinournature,soitisjustasimportantwegive peoplewith complex communication disabili-tiesthesameopportunities.

PeoplewhouseAACoftendon’tgettointeractso-cially,sousinganAACdevicefeelslikehomeworktomanyofthem.ThisiswhyitissoimportantwegivepeoplewithAACanopportunitytointeractsocially.IfwearegoingtohavesuccesswithpeoplewhouseAAC,weneed tocreateopportunities for themtointeract with people without making it seem likework.

Itbeginswiththefamilyunit.Thisiswherewegetalotofourinteraction,soweneedtohaveactivitiessetupsothatthepersonwhousesAACisincludedin the activities. These social interactions will de-velop their language skills because itwill help de-velopwhattheyhavebeenlearningtodoinschoolandtherapy.Thefamilyunitcanhelpcorrectsyntaxandgrammar,allwhilehavingfuntogether.Itisgo-ing tohelp themgetmasteryofeverydayvocabu-lary.

Thisalsoiswhereapersonlearnssocialskills.Aper-son needs to be able to learn how to listen, taketurns, and reply properly within a social setting.

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They can have achieved all of the linguistic andoperationalcomponents,butifapersonwithacom-plex communication disability can’t use them in asocial setting, the communication goal won’t beachieved(Light&McNaughton,2014).Ifyouareso-ciallyisolated,youaren’tgoingtolearnhowtousethese vital tools. It isn’t only language that buildsrelationships;it’slearninghowtoproperlyinteractwithothersandrespondappropriately.The familyunitisagreatplacetostartlearningabouttheseso-cialskills.

StrategicCompetence

Thestrategic competence involves theuseofAACdevices throughout a variety of settings and for arange of purposes. Light has expanded the defini-tion of adequacy of communication to includemotivationoftheperson,attitudeofapersonandhisorhersupportteam,confidenceofaperson,andthe resilience of a person (Light & McNaughton,2014).Ifanindividualisn’tmotivatedtocommuni-cate,itisn’tgoingtohappen.Ifthefamily,teachers,and other professionals aren’t willing to embraceAAC,theindividualisn’tgoingtowanttouseitforcommunication.Failuretobesupportiveandcreatemotivation will affect their confidence and resili-encetouseAAC.This is logical,andyetwe’restillwonderinghowtoget individuals toembraceAACandbecomeefficientcommunicators.

Myfamilyembracedmycommunicationdevice,sowecameupwithourowngamestoplaywithit.Weplayed a lot of Uno, Monopoly, and other boardgames.Ihadtosaythingslikepickupthatcard,ormove my guy over there, and so on. However, Ilearnedhowtotalkduringgamestoo.Ilearnedhowto take turns, listen to them, ask questions, andeventrashtalkduringthegamewewereplaying.

Ihadaone-on-oneaidethroughlunchforthirdandfourthgrade.Myone-on-oneaidewouldwriteallofmytests,andalsohelpmewiththepersonalcarestuff.Afterlunch,studentswouldhelpmecompletetherestof theday’s schoolwork.Theywould taketurns helping me, which made them more

comfortableinteractingwithme.Theseinteractionssoon developed into friendships. I would havefriendsofminevolunteeringtodorecesswithme,which was either playing a game inside theclassroomorplayingsocceronanotherareaoftheschool’splayground.Thesesocialinteractionsweresoimportanttomydevelopmentthatwefoughttokeepmeinthesameschooldistrictformymiddleschoolyears.Ibelievewithoutthissocialinteractionin these early years, I wouldn’t have been asequippedasIwaswhenIwenttocollege.Ibelievemysocialdevelopmentstartedthisearly,whichweneedtorecognize,too!

Whilelanguageskillsaretaughtandlearnedattheeducationallevel,theyaremostlylearnedwhenweplayandaresocialwithourpeers.Itisdifficultlearn-inglanguagewithoutacommunicationdisability.ItisevenmoredifficultwhenyouarelearninghowtouseanAACdeviceaswell.This iswhyweneedtoincorporatesocialactivitieswhenapersonislearn-inghowtouseanAACdevice.

This is why I am encouraging clinicians to makelearningAAClessaboutwork,andmoreaboutfun.Learning languageskills isn’t supposed tobeeasy,but it also isn’t supposed to be a grind. You’resupposed to have fun as you are developinglanguage, and in my experience this fun part isgettingleftout.

NewOpportunitiesforAACUsers

The implication of social media has changed thelandscapeofoptionsofsocializationforpeoplewithcomplexcommunicationdisabilities.Inordertousesocialmediaeffectively,anindividualneedstohaveadvanceduseoffunctionallinguisticskills,aswellasadvanced use of operational skills (Light,McNaughton, 2014). Social media can be a greattool for somebody using AAC, but they need toknowhowtoreadandtheyneedtoknowhowtogatherandpostmeaningfulpictures.

Insomeways,socialmediahastakendowntheso-cial barriers for apersonwhousesAAC. They can

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interact with people on Facebook, Twitter, Insta-gram,etc.withouthavingthestigmaofhavingtheircommunication partner waiting for the response.Social media does have some advantages and Iwouldarguethatsocialmediaisagreatwaytokeepintouchwithpeopleyoualreadyhaverelationshipswith,butitisn’taplacetobuildlonglastingrelation-ships. Inmy experience, long lasting relationshipsare built with face-to-face conversations. This iswhereanindividuallearnsthosesociolinguisticskillsthatareneededtobuildthoselong-lastingrelation-ships.

As I have traveled around to different places,events,andconferences,IhavenoticedthatmanyprofessionalsworkinginAACarefocusingonmeet-ingtheeducationalstandards. It'sthelogicalthingtoworkonandIwouldsayitistheeasiestthingtowork on. However, teaching people how tocommunicate socially has been overlooked. Wedon'tknowhowtoteachthisandthusweworkonthethingsthatweknowhowtodobest.However,bydoingthat,wearelimitingtheperson.ThegoalofAACshouldbetosayanythingthatyouwanttosay. It isn't about telling a personwhat you needand/or want. It's about becoming an effectivecommunicator,soyoucanbuildrelationships.Build-ingrelationshipshelpsyoutonetwork,whichhelpsyoubecomeanythingthatyouwanttobecome.

Thisiswhyweneedtochangeourapproachregard-ingAAC.Weneedtomakeitmoresociallyorientedbecausethatishowmostpeoplelearntobuildontheirlanguageskills.ThereisoneactivitythatIwishIwouldhavehadmyselfgrowingup.IwishIwouldhavehadamentortotalkwithandtoaskquestionsto. I believe a mentor and mentee relationshipwouldbebeneficialtoeverybodyinvolved.Itwouldgivethementeeanopportunitytoaskquestionstosomebodythathasbeentherealready.Thiswouldbe an important connection because the mentorcouldhelpthementeewithdifferenttypesofissues.Plus, the mentor could help guide them throughdifferent scenarios they are going to go through.ThisiswhyIhavestartedamentorprogram.

BeCOME:AAC-BuildingConnectionswithOthersthroughMentoring&EducationaboutAAC

BeCOME: AAC is committed to assisting personswithspeechdisabilitiestoliveinfulfillingways.Webelievethatthecornerstonetoafulllifeisderivedfrom the ability (1) to participate in meaningfulrelationshipswithothersand(2)engageineverydaysocial interactionsasa fully ratifiedparticipant. Inorder to address this primary objective, BeCOME:AAC is focused on providing tools and services topeoplewhouseAACinordertoenableandenhancecommunication leading to social integration andcommunitybuilding.Specifically,BeCOME:AACwilldevelopanddistributeeducationalmaterials,facili-tatementoringrelationships,andprovideresourcestosupportlifetransitionsforpeoplewhouseAAC,all with the specific purpose of relationship andcommunitybuilding.

BeCOME:AACwantstohelpeverycommunityde-velopasocialgroupthatwouldgettogetheranddofunactivitiestogetheronaweeklyormonthlybasis.These activities would be social activities, whichwouldallowpeoplewhouseAACtheopportunitytointeractwithotherpeople.Wewanttohaveactivi-tiesthatallowthepersonnotonlytobesocial,butalsohelpthemgivesomethingbacktothecommu-nity.

Mentors

This iswhereBeCOME:AACfeelshavingamentorwhousesAACisveryhelpful.OurgoalistomatchuppeoplewhoaresuccessfulusingAACwithbegin-nersusingAAC,sothattheycanhaveamentorwhoknowswhattheyaregoingthrough.Thementorcanhelpthepersonlearnhowtotaketurns,listen,etc.These are all important skills to learn, and theseskills can be learned in the context of a socialinteractiveactivity.

Mentors setupa time tomeetwith theirmenteeone-to-one.Thisiswheretheycanworkonactivelylisteningtoeachotherandtakingturnsrespondingto each other. Children and adults who are first

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learninghowtouseanAACdevicedon’thavemanyopportunitiestogetintoaoneononeconversation.Whenthisdoesn’thappen,theyhaveadifficulttimelearning how to take turns listening, and takingturnsrespondingtooneanother.Inthissetting,thementorandmenteecantalkaboutsomethingthatinterests thementee,which isgoing tohelp themlearnhowtotaketurns.Asthisishappening,theyarestilldevelopingtheirlanguageskillswhilebeingmoremotivatedtotalk.Thisbeginstohelpdeveloptheirconfidence,whichwillmakethemmoreresili-ent.GroupActivitiesA mentor also could set up a group activity. Thisactivity should make the group be social, so thattheyhavetointeractwithoneanother.Asthisactiv-ityisgoingon,eachmentorcanobserveamenteeinteractingwithotherpeople.Thementorcanworkonsocialinteractionswithinthegroupsetting.Oneactivitycouldbehavingagroupofpeoplegotoananimalshelter,andhelptheshelterbyinteract-ingwiththepuppiesandkittens.Astheyarelearn-ing to play with the puppies, telling them to sitdown, comehere, liedown, stop it, etc., theyaredoingitinasocialsetting.Theywouldhavetoworkas a team,whichwouldmake themsocializewitheach other, as they are helping train the puppies.This would allow the group of people to interactwith one another, but also it would give them asense of purpose. They would be helping thecommunityoutbycomingandgivinganhourtoplaywithanimals.Itisagreatthingtohaveabuddytocommunicatewith.Actually,sometimesabuddycangetmoreoutoftheperson,sothisisanactivitythatisveryuseful.Thiswillhelppromotelanguage,whichwillhelpherorhimdevelopmoretoolsforlife.Youcanorganizeasupportgroup.Youcanbringto-getherabunchofpeoplewhouseAAC,sothattheycan support one another. This would be anotherwaytodoagroupactivitytogether.Thegroupcan

pickanactivitytheywouldliketodotogether,andgodoit.Theycouldpracticeusingtheircorevocabu-larytogether,whichwouldhelpthemenhancetheirlanguageskills.

SettingtheStageforFutureOpportunitiesTheserelationshipsthatarebeingdevelopedaresoimportant,notonlyfortheirlanguageskills,butalsofortheirlifeandleadershipskills.Networkingisavi-talaspectingettingemploymentandbeingputintoaleadershiprole.Withouttheabilitytonetwork,aperson will have a difficult time finding a role inleadership. This is why building relationshipswithco-workers and committee members is so vital.Theyneedtohavethoseconnectionsbecausewith-outthemitisgoingtobedifficultforthemtolearnhowtobealeader.Itisgoingtobedifficultforthemtofindaleadershiprolewithoutarelationshipwitha committee member or somebody already in aleadershiprole.In my experience, leadership skills are hard toachieve formanyaugmentative communicators ingeneral. Everything that hasbeendiscussedup tothis point would be very helpful in developingleadershipskills.Itwouldbeanappropriatetaskforacamporasupportgrouptoappointofficersofthegroup.Eachofficerwouldhavetheopportunitytoplananactivityforthegroup,whichwouldbevotedonbyeverybodyinthegroup.Itwouldgiveevery-bodyatasteofwhatitisliketobealeader,whichwouldhelpthemdevelopanotherskill.The fact isweneedmorepeoplewhouseAAC tobecome leaders. Idon’tbelieveourvoice isheardenough, so we need to rectify that problem.Manufacturers, speech-language pathologists, andothersinthisindustryneedtounderstandwhatwedesire.ThethingthatsomeAACusers,suchasmy-self,desirethemostistheabilitytoaccesscommoneveryday language, so that we can develop otherskills. By givingus theopportunity to developourautomaticityusingcorevocabulary,automaticityinusingcoresyntax,automaticityincoremorphology,andautomaticityincorepragmatics,youaregiving

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usachancetocontributetosociety.

All these activities are great topromote and I be-lieveeveryactivitywillhelptheindividualdeveloplanguage,whichwould lead to developing leader-shipskillsandbuildingrelationships.Thegoalindo-ingthis is tostopthesocial isolationmanypeoplewithAACexperience.Everybodyneeds to feel liketheyareapartofsomething,especiallyapartofacommunity.PeoplewhouseAACareneedingandwantingthataswell.

Itstartsbygivingthemaccesstoeverydaylanguage.Whentheyhaveaccesstoeverydaylanguage,theycanlearnhowtobuildsentences.Thosesentencescanleadintodevelopingrelationships.Whenaper-soncanbuildrelationships,theycanaccomplishanygoaltheyset.

Declarations

ThiscontentissolelytheresponsibilityoftheauthoranddoesnotnecessarilyrepresenttheofficialviewsofATIA.Nofinancialrelationshipsweredisclosedbytheauthorofthispaper.Theauthordisclosedanon-financialrelationshipwithUSAAC.

References

Light,J.(1989).Towardadefinitionofcommunicativecompetenceforindividualsusingaugmentativeandalternativecommunicationsystems.AugmentativeandAlternativeCommunication,5(2),137-144.DOI:10.1080/07434618912331275126

Light,J.&McNaughton,D.(2014).Communicativecompetenceforindividualswhorequireaugmentativeandalternativecommunication:Anewdefinitionforaneweraofcommunication?AugmentativeandAlternativeCommunication,30(1),1-18.DOI:10.3109/07434618.2014.885080

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UseofMobileTechnologybyAdultsWhoUseAugmentativeandAlternativeCommunication:VoicesfromTwoCountries

DianeNelsonBryen,PhDProfessorEmerita,TempleUniveristy–USA

JuanBornman,PhDProfessorandDirector,CenterforAugmentativeandAlternativeCommunication,

UniversityofPretoria–SouthAfricaJohnMorris,PhD

ClinicalResearchScientist,ShepherdCenter–USAEnidMoolman

Lecturer,CenterforAugmentativeandAlternativeCommunication,UniversityofPretoria–SouthAfrica

F.MarkSweatman,PhDDataAnalyst,ShepherdCenter–USA

Abstract

Mobiletechnology–cellphones,smartphonesandtablets – has expanded communication and socialinteraction, commerce, and access to informationfor many people with disabilities. Little is knownabouttheuseofthesemainstreamtechnologiesbyadults who use augmentative and alternativecommunication(AAC).Informationcomparingtheiruse by adults who rely on AAC from both high-income and low or middle-income countries isnonexistent.Thisarticlepresentsdataontheuseofmobile technology by 38 adults from the UnitedStatesand30adultsfromSouthAfricawhouseAAC.Results, focusing on outcomes and benefits,indicate that most of the participants from bothcountries use some form of mainstream mobiletechnology.Most report that theirmobile devices

are important, but some find it difficult to userequiringavarietyofmodifications.Morethan50%ofparticipantsfromeachcountryusedtheirmobiledevicesfortext-messaging,webbrowsing,keepingadirectoryofcontacts,voicecalling,sharingphotosor videos online, listening to music, and socialnetworking. Recommendations are made forindustryandpeoplewhorelyonAAC.

Keywords: augmentative and alternativecommunication,AAC,cellphones,mobile technol-ogy

Introduction

Use of mobile technology – cell phones,smartphonesandtablets–hasgrowndramatically.By the turn of this century, cell phone use had

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reachedamajorityofthepopulationinCanada,theUnited States, Australia, Germany, Singapore, theUnited Kingdom, and Italy (Bryen & Moolman,2015). Although Africa had only 15 million cellphoneusersattheturnofthecentury,thisgrewto387.7millionin2011,becomingthesecondlargestmobile phone market in the world after Asia(DlaminiZuma,2014).

According to thePewResearchCenter (2015), cellphones (portable telephones that use cellulartechnology)areascommonintheUnitedStates(ahigh-incomecountry)astheyareinSouthAfrica(alow- and middle-income country). Smartphones(cell phones that run complete operating systemsand that can access the Internet and applications(“apps”) with features such as calendars, mediaplayers,GPSnavigation,andwebbrowsing)arenotaswidelyusedduetocost,butarerapidlygainingpopularity(Bryen&Moolman,2015).Slightlymorethan34%ofSouthAfricansownsmartphonescom-pared to 64% in theUnited States (Pew ResearchCenter,2015).

Cell phones and,more recently, smartphones andtablets have become increasingly ubiquitous be-causetheyareportableandmakepersonalorwork-related communication possible from almost any-where(Stock,Davies,Wehmeyer,&Palmer,2008).Accesstomobiletechnology,asubsetofthelargerinformation and communication technology (ICT),has expanded communication, social interaction,andcommerce,andhas improvedaccess to infor-mation via the Internet. Furthermore, mobiletechnology is not dependent on costly infrastruc-tures required for the use of landline telephonesanddesktopcomputerswherepenetration insub-Saharan Africa is close to zero (Pew ResearchCenter,2015).

MobileTechnologyandPeoplewithDisabilities

Thepotentialofmobiletechnologytoimprovethelivesofpeoplewithdisabilitiesremainslargelyun-tapped (Scope,2013).According to theCenter foranAccessibleSociety(2014),mobiletechnologyhas

potentialtosubstantiallybroadenthelivesandin-creasetheindependenceofpeoplewithdisabilities.Increasingly,theycannowloginandordergrocer-ies, shop and pay for appliances, research healthquestions, participate in online discussions, navi-gatecities,travelandcatchupwithfriends,ormakenewonesatanytimeandfromanywhere.

Internationally, the importanceofmobile technol-ogy in equalizing opportunities for people withdisabilities has been reinforced by theUnitedNa-tions Convention on the Rights of Persons withDisabilities(CRPD).Article9oftheCRPDnotesthatinformation and communication technologies,including mobile technology, enable people withdisabilities to livemore independentlyandpartici-patemorefullyinallaspectsoflife(UnitedNations,2006).Despitethesebenefits,peoplewithdisabili-tiesstillhavemorelimitedaccesstomobiletechnol-ogythantheirnon-disabledpeerswithonly35%ofpersonswithdisabilitiesinNorthAmericahavingac-cesstothesetechnologiescomparedto75%ofpeo-ple without disabilities (Duchastel de Montrouge,2014).

Mobile Technology for People Who Rely onAugmentativeandAlternativeCommunication

The CRPD recognized the importance of mobiletechnologyfortheapproximately1billionindividu-alswithdisabilitiesworldwide,includingthosewithcomplex communication needs who requireaugmentativeandalternativecommunication(AAC)approaches.Nguyen,Garrett,Downing,Walker,andHobbs (2008) demonstrated that when mobilephones were interconnected with the individual’sAAC device, theywere able to effectively use thephoneinitsmanymodesofoperation,resultinginagreatersenseofindependence,safety,andsecurity.The use of mobile phones also contributed toimproving their communication skills, resulting ingreater self-confidence in conversation and socialinteractions.

Smartphones and tablets are increasingly used tomediate other areas of social interaction beyond

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interpersonal communication. Shane, Blackstone,Vanderheiden,Williams,andDeRuyter(2012)notedthat modern consumer technology is used forsearching for information, online services such asbanking, entertainment (books, news, video),education,healthandsafety,personalorganizationtoolssuchasaddressbook,calendar,clock,andcus-tomer services like airport check-in. Smartphones,consequently, offer great opportunity for peoplewhouseAACtoaccesstheworld,whilesimultane-ouslycreatingchallengestoensurethatAACusersarenotleftbehindasmobiletechnologyadvances.Finally,mainstreammobiledevicesaremorestylish,which has resulted in them becoming fashionaccessories compared to AAC devices, which lackthe“coolfactor”andoftenlookasiftheywerede-signedforchildrenorcarryothermarkersthatsig-nifydisabilityinsomeway(Foley&Ferri,2012).Despitethepotentialbenefitsofmobiletechnology,little informationhasbeenavailableon theactualuse of these technologies by adults with complexcommunication needs who use AAC, how theyselectandadaptthem,andtheirexperiencesusingthem.EarlyresearchfoundthatadultswhorelyonAAChadlimitedaccesstocellphones(Bryen,Carey,&Potts,2006).Agapwasreportedincellphoneuse(20%fortheirsampleofadultswhouseAACcom-paredto57%forthenon-disabledUSsample).LaterresearchbytheRehabilitationEngineeringResearchCenter on Wireless Technology (Wireless RERC,2014)foundthatadultswhoreliedonAACusedmo-biledevicesat substantially lower rates than theirpeers from other disability groups, such as thosewhohavevisualorhearingdisabilities.MorrisandBryen(2015)providedamorepositivepictureaboutthe use ofmobile technology by adults in the USwho rely on AAC. However, respondents in theirstudy continued to lag behind respondents withother disabilities as well as behind the generalpopulation in their use of these mainstreamtechnologies.Giventheworldwideexpansionintheuseofmobiletechnologyandtheincreasedneedtomakethesepowerfultechnologiesmoreaccessibleto people with disabilities, the question remainswhether adultswhouseAAC in bothhigh-income

andlow-ormiddle-incomecountriesareusingthemat similar rates and for similar purposes andactivities.PurposeoftheStudyThepurposeofthisresearchistodescribetheuseofconsumermobiletechnologybyadultswhorelyonAACintheUnitedStates(ahighincomecountry)andSouthAfrica(alow-ormiddle-incomecountry).By studying this rapidly growing and importantmeans of communication, we will have a betterunderstandingofcurrentuse,barriers,andneededchangesfromtwodifferentcultural,contextual,andsocio-economicperspectives.Basedon the resultsof this research, recommendations can focus onboth local and international initiatives needed toensure equal access to mobile technology forindividuals with disabilities who rely on AACtechnologies.

MethodA descriptive survey design (McMillan &Schumacher, 2010) was used to describe the re-sponsesof38adultsfromtheUnitedStatesand30adultsfromSouthAfricawhorelyonAACusingtheSurvey of User Needs (SUN4) (Morris, Mueller,Jones&Lippincott,2014).MaterialsThe Survey of User Needs (SUN) was originallylaunched in the United States in 2012 by theRehabilitation Engineering Research Center onWireless Technology, also known as the WirelessRERC.TheSUNhasbeenupdatedthreetimesinor-dertokeepupwiththerapidpaceoftechnologicalchangeandtoensurethatdataparticularlyrelevanttopeoplewhouseAACwereincluded(Morrisetal.,2014). SUN4 can be viewed athttp://www.wirelessrerc.org/content/projects/sun-overview.SUN4hasfourparts.Part1coversdemo-graphicvariables (i.e.,age,gender,ethnicity,high-esteducationallevelattained,annualhouseholdin-come, living conditions, type of employment, and

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whether the surveywas completed independentlyorwithhelp).Part2focusesontheparticipantabili-tiesanddisabilities,aswellasthetypesofmobiletechnology devices used. Part 3 focuses on theparticipant use of mobile devices, for examplewhethertheyownamobiledevice,thetypesofmo-bile devices they use and the activities theywereusedfor,satisfactionwiththeirmobiledevice,howtheparticipantdecidedontheparticulardevice,aswellasthetypesofchangesthatweremadetoit.Finally,Part4focusesonthevariousactivitiesandfunctionsforwhichthemobiledevicesareusedandhowoftentheyareused.Questionsalsofocusedonsocial networking activities and the use ofmobileapps.The content validity of SUN4 was established byconducting interviewswith subjectmatterexpertsin the mobile device and service industries andregulatory agencies, accessibility and assistivetechnology experts, advocates for people withdisabilities,andpeoplewithdisabilitiesthemselves,as part of the development process. A few itemswere adapted from other established survey re-search,includingtheNationalHealthInterviewSur-vey(NHIS)conductedbytheUSCentersforDiseaseControl and Prevention (CDC), and the Pew Re-searchCenter’son-goingresearchonmobiledeviceuse (Duggan& Smith, 2013). Finally, the typologyused to identify respondents’ functional abilitieswasadaptedfromtheAmericanCommunitySurvey(ACS).Five adaptations focusing on ensuring cultural,contextual, andmetric equivalenceweremade totheSUN4foruseintheSouthAfricancontext.Thesewere:(a)changestotheethniccategoriesused,(b)changestothecategoriesinwhichhighestlevelofeducationwasdescribed,(c)categoriesusedtode-scribe household income and the metric used(South African Rand not United States Dollar), (d)the examples of mobile technologies and serviceprovidersspecifictotheSouthAfricancontextwereincluded aswell as a category for low technologyAAC (communicationboards), and (e)metric usedfor the costing of apps was changed (Bornman,

Bryen,Moolman,&Morris,2016).ParticipantRecruitmentFortheUnitedStatessample,conveniencesamplingwasusedtoobtainasampleofadultswithcomplexcommunicationneedswhorelyonAACforface-to-face communication. Study participants were re-cruited through the Wireless RERC’s ConsumerAdvisory Network, a nationwide network ofconsumers with disabilities. Recruiting was alsodone by asking individuals working at national,state, and local organizations to disseminate theinvitationtoparticipatetotheirnetworksofpeoplewith disabilities who rely on AAC. Finally, infor-mationaboutSUN4wasposted to theAugmenta-tiveCommunicationOnlineUser'sGroup(ACOLUG),an international listserv for people who use AAC,and was sent to individuals working at national,state, and localorganizations.Asa resultof theserecruitmentefforts,a totalof38adultswithcom-plexcommunicationneedswhouseAACcompletedSUN4.For the South African sample, three recruitmentstrategies were used: recruitment from (a) anempowerment project for adults with complexcommunicationneedswhouseAAC,(b)e-mailtar-getedatthispopulation,and(c)outreachtoinstitu-tions for individuals with severe disabilities. Fromthisrecruitmentprocess,atotalnumberof30SouthAfricanadultswithcomplexcommunicationneedswhouseAACwereidentifiedandcontacted.Inclu-sioncriteriaforbothcountrieswerethesame.Tobeeligible for this study, participants had to (a) beadults, 18 years or older; (b) have complexcommunication needs, (c) rely on some form ofspecialized AAC for face-to-face communication,and (d) provide consent. Details about the SouthAfricanandtheUnitedStatessamplesareprovidedinTables1and2.ProceduresInSouthAfrica,humansubjects researchapprovalwas obtained from the University of Pretoria. All

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potentialparticipantsreceiveddetailedinformationaboutthestudymakingitclearthatparticipationinthestudywasvoluntaryandthattherewouldbenonegative consequences if they declined participa-tionorwithdrewatanytime.PotentialSouthAfri-can participants completed an informed consentform. All potential participants consented. In theUnitedStates,becauseofthenon-invasivenatureofthe survey questions and the inclusion of only

adults, the research received a waiver ofdocumentation of informed consent from the re-view board at the researchers’ institution for theparticipantsfromtheUnitedStates.IntheUnitedStates,participantscompletedthesur-vey via SurveyMonkey®, a web-based survey ser-vice.Althoughallparticipantswereofferedalterna-tivemethodsforresponding(e.g.,email,phone,or

Table1UnitedStates(US)andSouthAfrican(SA)Participants’DemographicInformation

Demographicinformation%ofUS

participants(N=38)

%ofSAparticipants

(N=30)CompletedSUN4ontheirown 68% 13%Meanage(inyears)andSDGender(%female)

42(SD.=16.4)

39%

33(SD=12.0)

37%Race

• BlackorAfricanAmerican 13% 33%• White 74% 67%• Asian/PacificIslander 3% NA• Hispanic/Latino 3% NA

Householdincome(above$35K/60KRand) 38% 40%Education

• Notapplicableornoschooling 3% NA• Attendedprimaryschool 5% 10%• HighschooldiplomaorGED 16% 14%• Posthighschooleducation 76% 17%• Attendedspecialschool NA 59%

Employmentstatus • Employedfulltime 29% 3%• Employedparttime 21% 13%• Retired 13% 3%• Unemployed 32% 80%

Livingsetting • Urban/suburbanarea 79% 90%• Ruralarea 21% 10%• Livesalone 19% 7%

Note:The2015officialpovertylevelsforahouseholdoffourwerebasedontheFederalRegisterbytheU.S.DepartmentofHealthandHumanServicesundertheauthorityof42U.S.C.9902(2)fortheUnitedStatesandfromhttp://theconversation.com/how-current-measures-underestimate-the-level-of-poverty-in-south-africa-46704forahouseholdoffourinSouthAfrica.

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face-to-faceinterview),nonewasrequested.Incon-trast, most South African participants relied onsomeone to record their responses -- either theirprimarycaregiversortrainedresearchassistants.DataAnalysisDescriptivestatisticswereusedforthedataanalysisgiventhatthisresearchwasexploratoryinnature.Information from the survey was coded inSurveyMonkey® and frequencies and percentageswere calculated for each country. Due to somedifferences in the recruitment of participants anddatacollectionproceduresbetweenthetwocoun-tries,inferentialstatisticswerenotused.

ResultsDespite geographic, demographic, and economicdifferences between the United States and SouthAfrica, there were many similarities between thetwo samples. Table 1 shows that the gender andethnicmembershipinthetwosamplesweresimilarwith more male than female participants. Partici-pantsmostlylivedinurbanorsuburbanareas,livedwithothers,andhadincomesbelowtheirrespectiveofficialpoverty levels.Thetwosampleswerebothover-represented by participants who are white,despite the fact that Black South Africans are a

numericalmajority.Education levelsandemploymentstatusdiddifferbetweenthesamplesfromthetwocountries.IntheUnited States sample, 92% reported completinghighschool,obtainingaGED,orhavingsomeposthighschooleducation.Incontrast,only31%oftheSouthAfricanparticipantsreportedcompletinghighschool,obtainingaGED,orhavingsomeposthighschooleducation.Furthermore,50%ofthepartici-pants from the United States reported being em-ployedeitherfullorpart-time.Thisisincontrastto80% of the South African sample reporting beingunemployed.As shown in Table 2, participants from bothcountries reported experiencing multipledisabilities. More than three-quarters of bothsamples reported having complex communicationneeds (i.e., difficulty speaking so people canunderstand). The majority of respondents fromboth countries also reported having difficultiesusingtheirarms,usingtheirhandsandfingers,anddifficulty walking and climbing stairs. This findingshows that participants from both countriesreported having multiple disabilities, not justcomplexcommunicationneeds.Asmallpercentageofparticipants fromeachcountry reportedhavingdifficulty with nervousness and anxiety,

Table2TypeofDifficultyExperiencedbyParticipantsfromtheUnitedStates(US)andSouthAfrica(SA)

Typeofdifficulty%US

participants(N=38)

%SAparticipants

(N=30)Frequentworry,nervousness,oranxiety 24% 17%Difficultyconcentrating,remembering,ormakingdecisions 21% 27%

Difficultyseeing 21% 13%Difficultyhearing 34% 7%Difficultyusingarms 61% 60%Difficultyusinghandsandfingers 66% 70%Difficultywalkingandclimbingstairs 66% 73%Difficultyspeakingsopeoplecanunderstand 82% 100%

Note:Percentagesaddtomorethan100%becauseseveralparticipantsexperiencedmultipledifficulties.

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remembering,decision-making,andseeing.Participants from each country were asked aboutthe types of specialized technologies they use toaddress theirdisabilities.Results shown inTable3indicatethatthemajorityofparticipantsfromeachcountry use high-techAACdevices, either special-ized speech-generating devices (SGD) or text-to-speech software. A high percentage from eachcountryalsoreportedusingwheelchairs.Giventhemoderate rate of hearing difficulties among theparticipantsfromtheUnitedStates,itisnotsurpris-ingthattheyalsoreportedusingmorehearingaidsthan those from South Africa. The types ofspecializedassistivetechnologyusedbyparticipantsfromeachcountryreflectthefunctionaldifficultiespreviouslyreportedinTable2.Datapresented inTables4and5 illustratemobiletechnology device ownership and describe thesource(s) used to select this technology. Whenasked about their ownership and use of mobiletechnology devices, the majority of participantsfrom both countries reported ownership. It isinterestingtonotethatforbothsamples,thehigh-est percentage of ownership was that ofsmartphones -- 67% for SouthAfricanparticipants

and49%ofthosefromtheUnitedStates.Bothcoun-triesreportedsmallerpercentagesofownershipofbasiccellphonesandtablets.Asshown inTable5,participantsreportedusingavarietyofsourcestoselecttheparticularmobilede-vicetheyuse.Thelargestpercentagereportedthattheir selection was based on recommendationsfrom familymembers or healthcare professionals.Participants from theUnited States also relied ononlineconsumersourcessuchasblogsandlistservs,with50%ofparticipantsfromtheUSselectingtheirdevices based on recommendations from onlineconsumersources.ThispotentialresourcewasnotusedatallinSouthAfrica.Websitesofmobileser-vicecompanieswereusedlessfrequentlybypartici-pantsfromtheUnitedStates(39%)andevenlessbySouthAfricanparticipants(7%).Thedevicepackagelabelswiththelistoffeatures,aswellasinformationprovided by a salesperson, were also usedinfrequently in both countries. It is important tonote from Table 5 that many of the participantsfromeachcountryusedmorethanoneresourcetoselecttheirmobiledevice.Finally,almostone-thirdoftheSouthAfricanparticipantsreportedreceivingtheirmobiletechnologyasadonation,gift,orasaloan.

Table3PercentagesofSpecializedAssistiveTechnologiesUsedbyParticipantsfromtheUnitedStates(US)and

SouthAfrica(SA)

TypeofspecializedassistivetechnologyUS

participants(N=38)

SAparticipants

(N=30)Screenreader 16% 7%Screenmagnifier 5% 3%Hearingaid 26% 3%Speech-generatingAACdevice 100% 57%Text-to-speechsoftware 45% 53%FabricatedAACcommunicationboard NA 50%Wheelchair 61% 70%Crutches,cane,orwalker 21% 7%

Note:Percentagesaddtomorethan100%becauseseveralparticipantsusedmorethanonetypeofassistivetechnology.

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DatapresentedinTable6summarizesparticipants’overallpurposeforusingtheirmobiledevices,theirimportance and satisfaction, ease of use, andchanges made to their mobile technology. ThemajorityofparticipantsfromtheUnitedStatesre-portedusing theirmobiledevices forbothprofes-sional and personal uses while the South Africanparticipants reported that their devices are usedprimarilyforpersonalpurposes.Thisfindingreflectsthe differences between the countries in theemploymentstatusofparticipants(referbacktoTa-ble1).Regardlessofthepurpose,therewasalmostunanimous agreement among participants fromboth countries that the use ofmobile technologywasimportant.

Thiswasnotthecaseforsatisfactionandeaseofusewiththesemobiletechnologies.Severalparticipantsfrom each country shared some level ofdissatisfactionwiththeirmobiletechnology,notingdifficultywiththeeaseofuse.Whenaskedaboutchanges/modificationsmadetotheir mobile device, almost half of South Africanparticipantsreportedthatnochangesoradditionswere made to their mobile devices (47%).Respondents from the United States provided aslightlydifferentviewwithonly14%reportingnotmaking any changes to their off-the-shelf mobiledevices. Exploring the nature of the changes, thefollowingmodificationsweremadetotheirmobile

Table4PercentageofParticipants’OwnershipofMobileDeviceintheUnitedStates(US)andSouthAfrica(SA)

%USparticipants

(N=33)

%SAparticipants

(N=30)Ownsamobiledevice 85% 100%

• Basiccellphone 6% 23%• Smartphone 49% 67%• Tablet 21% 10%• Other(e.g.,laptop) 9% 0%

Table5HowMobileTechnologywasSelectedbyParticipantsfromtheUnitedStates(US)andSouthAfrica(SA)

Sourcesofinformation%US

participants(N=28)

%SAparticipants

(N=30)Recommendationsfromfriend,family,healthcareprofessional 61% 33%

Packagelabelwithlistoffeatures 18% 13%Salesperson 18% 13%Onlineconsumersources(blogs,listservs,news,etc) 50% 0%Websiteofmobileservicescompanies 39% 7%Websiteofmobiledevicemakers 25% 30%AdvertisingonTV,radio,orinmagazinesornewspapers 29% 13%

Other(e.g.,donation,gift,borrowed) 21% 30%Note:Percentagesaddtomorethan100%becauseseveralparticipantsusedmultiplesourcesofinformation.

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devices:• Physicalaccessorieswereadded,suchasa

protectiveskinorcase,headset,Bluetoothdevice,screenoverlay,lanyard,orstylus;

• Assistivedeviceswereadded,suchashead

switch, switch, AAC device, neck loop, orTTY;

• Softwarewas added, such as a third-partytext-to-speech, screen reader, screenmagnifier,orotherappstoredownloads;

Table6Use,Importance,Satisfaction,Ease,andChangesMadetoMobileDevicesbyParticipantsfromtheUnited

States(US)andSouthAfrica(SA)

Useofmobiledevice%US

participants(N=28)

%SAparticipants

(N=30)Purposeforuseofmobiletechnology

• Professionaluse(workorschool) 0% 3%• Personaluse 28% 67%• Bothprofessionalandpersonal 61% 27%• Emergenciesonly 11% 3%

Importanceofuseofmobiletechnology • Veryimportant 89% 83%• Somewhatimportant 7% 13%• Notveryimportant 4% 3%

Satisfactionwithmobiletechnologyused • Verysatisfied 29% 50%• Somewhatsatisfied 54% 33%• Neithersatisfiednordissatisfied 10% 10%• Somewhatdissatisfied 7% 0%• Verydissatisfied 0% 7%

Easeofuseofmobiletechnology • Veryeasytouse 29% 43%• Easytouse 36% 30%• Somewhathardtouse 25% 17%• Hardtouse 3% 0%• Can’tuseitwithouthelp 7% 10%

Changes/additionsmadetomobiledevices • Nochangesoradditions 14% 47%• Physicalaccessoriesadded,suchasprotectiveskinorcase,

headset,Bluetoothdevice,screenoverlay,lanyard,stylus61% 33%

• Assistivedevicesadded,suchasheadswitch,EMGswitch,AACdevice,neckloop,TTY

32% 7%

• Softwareadded,suchasathirdpartytext-to-speech,screenreader,screenmagnifier,appstoredownloads

39% 27%

• Improvisedsolutions,suchashandstrap,Velcro,wheelchairmount

32% 7%

• Other,suchaslargerfont,differentscreenglassforheadpointer,protectivescreen

18% 10%

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• Improvised solutions were made, such ashand strap, Velcro, or wheelchair mount;and

• Otherchangeswerereported,suchaslargerfont,differentscreenglassforheadpointer,orprotectivescreen.

Therobustfeaturesandfunctionsbuiltintomobiledevices make them especially attractive forindividualswhorelyonspecializedAACdevices.Ta-ble 7 shows the types of activities in which theparticipants engagedwhen using theirmobile de-vice.Most of the 18 activities listed in the surveywereengaged inbysomeoftheparticipants fromeachcountry.Morethan50%ofparticipantsineachcountryengagedintextmessaging,webbrowsing,keepingadirectoryofcontacts,voicecalling,shar-ingphotosorvideosonline,listeningtomusic,and

socialnetworking.Basedonthecombinedpercent-agebeinggreaterthan100%ineachcountry,itcanbenotedthatmorethanoneactivitywasusedbyatleastsomeoftheparticipantsfromeachofthetwocountries.Finally,allparticipantswereaskedtoindicateiftheyhadexperiencedanyof11distinctsituationsusingtheir mobile devices in the previous 30 days. AsshowninTable8,theexperiencesidentifiedbythelargest percentage of participants were “Makingplanswithothers”(79%fortheUnitedStates,67%forSouthAfrica);“GettinginformationthatIneededrightaway”(68%forUnitedStates,47%forSouthAfrica);and“UsingforentertainmentorwhenIwasbored” (45% for the United States and 63% forSouthAfrica).



Typeofactivity%US

participants(N=28)

%SAparticipants

(N=30)Textmessaging 93% 80%Webbrowsing 79% 57%Email 71% 37%Keepingadirectoryofcontacts 75% 73%Downloadingapps 71% 43%Keepingacalendarofappointments 71% 43%Socialnetworking–Facebook2,LinkedIn3,Twitter4,etc 71% 57%Voicecalling 57% 50%Navigatingorwayfinding(usingGPSand/ormaps) 61% 23%Sharingphotosorvideosonline 57% 67%Usingvoicemail 54% 13%Watchingvideos 50% 40%Listeningtomusic 50% 60%Playinggames 43% 33%Videocalling 39% 3%Shopping 39% 0%Recordingvoicenotesorreminders 29% 10%Monitoringyourhealth 25% 0%Other 18% 17%

Note:Percentagesaddtomorethan100%becauseseveralengagedinmorethanoneactivity.

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DiscussionBefore summarizing themajor findings related tooutcomesandbenefits, it is importanttohighlightthatconductingabi-nationalstudyisnotwithoutitsinherentdifficulties.Despiteeconomic(e.g.,highin-comevs.middleor low income), geographic (e.g.,North America vs. sub-Saharan Africa), anddemographic differences between the twocountries (e.g., United States’ population ofmorethan 320 million as opposed to a South Africanpopulationoflessthan54millionin2015;majorityof United States’ population is white versus themajority of South Africa’s population is Black in2015), the two samples of adults with complexcommunication needs were similar in severalimportant ways. The majority of the studyparticipantsfrombothcountrieswerewhite,male,hadhousehold incomesbelowthemedian income

for their country, lived in urban or suburbansettings, were either unemployed or worked parttime, lived with other people, and experiencedmultiple disabilities associated with complexcommunication needs. Participants from bothcountriesusedavarietyofspecializedtechnologiesto address their disabilities with a large majorityusingspeechgeneratingdevicesandtexttospeechdevices to address their complex communicationneeds,aswellasusingwheelchairstoaddresstheirphysicaldisabilities.Somerelevantdifferencesbetweentheparticipantsfromthetwocountrieswere,however,noted.Theyincludedage,wheretheparticipantsfromSouthAf-ricawereyounger.Employmentstatusandeduca-tion level also differed, where more participantsfromtheUnitedStateswereemployedfull-timeandachieved higher education levels compared to



Typeofexperienceswithmobiletechnology%US

participants(N=28)

%SAparticipants

(N=30)Wasfrustrated–mobiledevicetooktoolongtouse 29% 30%Haddifficultyenteringalotoftext 43% 30%Haddifficultyreading–screenorthetextwastoosmall,screenreadercouldn’treaditoutloud 39% 17%

UsedmymobiledeviceforentertainmentorwhenIwasbored 61% 63%Pretendedtousemymobiledevicetoavoidinteractingwithpeoplearoundme 11% 10%

Wasinanemergencysituationwherehavingmymobiledevicereallyhelped 21% 27%

UsedmymobiledevicetogetinformationthatIneededrightaway 68% 47%%

Usedmymobiledevicetogetdirectionswhileoutsideofmyhomeoroffice 50% 23%

Usedmymobiledevicetomakeplanswithothers 79% 67%Turnedoffforaperiodoftimetogetabreakfromusingit 11% 13%WasinasituationwhereIhadtroubledoingsomethingbecauseIdidn’thavemymobiledevicewithme 18% 37%

Note:Percentagesaddtomorethan100%becauseseveralparticipantshadmorethanonerecentexperiencewithmobiletechnology.

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participantsfromSouthAfrica.OutcomesandBenefitsThe largemajorityofparticipantsfrombothcoun-triesownedorusedsomeformofmainstreammo-bile technology. This finding compares favorablywith2014dataaboutcellphoneownershipbythegeneral population in United States (89%), Africa(89%),andSouthAfrica(90%)(PewCenter,2015).Incontrasttoworkinglandlines,whichcontinuetobe common in the United States (60%), workinglandlines are almost non-existent in South Africa(2%). Low- or middle-income countries, such asSouthAfrica, have entered the digital and cellularages, bypassing the need for landline phones anddesktopcomputers.Thismaybeakeyreasonthatoneofthemajorfindingsofthisstudyshowedthatsmartphoneswereusedmore frequently thancellphonesnotjustinthehigh-incomecountrybutalsoinalow-ormiddle-incomecountry.Among the participants, texting was the mostcommonactivity in both countries. This comparesquite favorably with data from the study of cellphoneuseinthegeneralpopulationofAfrica(PewResearch Center, 2015). Although mobiletechnologyhasdifferentusesfordifferentpeople,itisclearthatcommunicationandsocialinteractionisimportant whether or not you live in the UnitedStates or in SouthAfrica andwhether you have adisability or not. Texting uniquely serves thecommunication needs of those who rely on AAC,since it bypasses theneed for speech.Due to thefact that sending and receiving text messages isasynchronous,itcompensatesforthefactthatusingspeech-generating devices is much slower thanspeech.Furthermore,itishypothesizedthattextingmay be especially attractive to individuals withcomplex communication needs becauseabbreviatedspellinghasbecomesotypicaltoallofuswhentexting.(e.g., lessfatiguingandlesstime-consuming).Amajorityofrespondentsfrombothcountriesalsouse their mobile devices to keep a directory of

contactsandtoparticipateinsocialnetworks.Onceagain,thisfindingdemonstratestheimportanceofsocially connecting with others and supports thefindings of Caron and Light (2015). Browsing thewebforentertainmentorforobtaininginformationwasapopularactivityformorethan50%ofmobiletechnology owners in this study. Other activities,such as getting health information and shopping,were engaged in by fewer participants, but donemore frequently by participants from the UnitedStatesthanthosefromSouthAfrica.Thismaybeat-tributedtotheloweravailabilityoftheseservicesinSouth Africa. That video calling was used infre-quently by the South African participants (3%) ispossibly related to the high cost of data use or,alternatively,becauseWIFIisnotyetfreelyavailablethroughoutthecountry.Outcomesfromthisstudydemonstratedthatmostrespondents noted the importance of using theirmobile devices. This finding supports recognitionthat mobile technology holds great promise torevolutionize lives as it provides all individuals,including those with complex communicationneeds,theopportunitytoconnectwithothers,andalsotoaccesseducation,commerce,employment,and entertainment from anywhere and mostly atanytime.(Caron&Light,2015;Foley&Ferri,2012).Despite thepromise thatmobile technologyholdsto enhance the lives of individuals with complexcommunication needs, data from this study alsofound that its use was difficult for approximatelyone-thirdoftheparticipantsfrombothcountries.Inaddition,forthosewhocouldusethistechnology,avariety of device changes or modifications wereneeded.Assuch,anadditionalburdenislikelytobeplacedon thispopulation to retrofit thedevice sothat it is accessible and easily used. This findingunderscorestheUnitedNationscalltopromotethedesign, development, production, and distributionof accessible information and communicationstechnologiesandsystemsatanearlystage,sothatthesetechnologiesandsystemsbecomeaccessibleatminimum cost (United Nations, 2006), and theneed forusingprinciplesofuniversaldesignwhen

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developingandmanufacturingmobiletechnology.LimitationsDesigning and conducting a bi-national study is acomplexprocess,especiallywhen trying toensurethat each sample is representative of the de-mographicsofeachcountrywhilealsotryingtoen-surethatthesamplefromeachcountryiscompara-ble. The complexity is more so when the targetpopulation, adults with complex communicationneeds who use AAC, is relatively small in size,heterogeneous, and not easily accessible due tomultipledisabilitiesaffectingspeech,language,andmobility. As a result, there were within samplelimitations in addition to between sample limita-tions.Within countries, each sample of peoplewho useAACwasnot representativeof theoverallpopula-tion.Theyweremoreliterateandmorehighlyedu-cated. Theymostly lived in urban/suburban areaswithveryfewfromeachcountrylivinginruralareas.Theywerealsomostlywhite.Inaddition,althoughhouseholdincomesofeachcountryrepresentedthecurrencies for their country and reported as theirrespectivemedian income(ReferbacktoTable1),theincomethresholdofthetwocountriesisnotthesame. The purchasing power of the South AfricanRand versus the United States dollar differs. Forexample, in the2015UBSPrices andEarningsRe-view, the amount of time an average worker indifferentcitiesacrosstheglobemustworktoearnenough topurchase staple consumer items (e.g.asmartphone),wascalculated.Theworkingtimere-quiredtobuyonesuchsmartphoneinNewYorkCityisapproximately24hr.comparedtoJohannesburg,whichis86.9hr.Consideringanaverage40-hr.workweek,thiswouldimplythatintheUnitedStatesonehalf-week’s work will buy this smartphone, whilejustmorethantwoweekswillberequiredinSouthAfricatobuythesamephone(UBS,2015).BecausecomplexcommunicationneedsresultingintheneedforAACisarelativelylowincidencedisabil-ity,itwasalsodifficulttoobtainalargerandmore

representativesample.Witharelativelysmallsam-ple size,we couldnotdo somebasic comparativestatistical procedures, nor could we explore therelationship between key demographics, such asgender, age, and education and mobile deviceownershipanduseineachcountry.Assuch,there-sultsofthisstudyshouldbeviewedwithsomecau-tion. However, this study on the use of mobiletechnologyisthefirstofitskindineachcountryandintwoverydifferentcountries.Itcanbeusedasacrediblebaselineforfurtherreplication.RecommendationsRecommendationsforresearchers.First,thereisaneedtoreplicatethisstudy,strivingwhereverpossi-ble,togetalargerandmorerepresentativesamplefrom each country. Of importance is the need tosecure better representation from marginalizedethnic and racial minorities who have complexcommunicationneedsandwhouseAAC.ThismaybequitedifficultsinceprogramsprovidingAACser-vicesthatserveassourcesfromwhichtorecruitre-searchparticipantsmayalsounderservemembersofminoritygroups.Specialeffortshouldalsobemadetorecruitpartici-pants from rural populations. Odendaal, Duminy,and Saunders (2008) suggest that in South Africatheremaybeadigitalandcellulardividebetweenruralandurbanpopulations.ThisrecommendationalsoappliestofutureresearchintheUnitedStatessince participants from rural areas wereunderrepresented in both the countries in thisstudy.However, given thatmobile technologyhasthepotentialtoreachruralareas,itisimportanttolearniftheyare,indeed,reachingpeoplewhohavecomplexcommunicationneedslivinginruralareas.Thereisalsoaneedtoreplicatethisstudygiventhemorerecentadvancesinmobiletechnologyandtheactivities for which they can serve. For example,within the past two years, manufacturers ofsmartphoneshaverecognizedtheneedtobuild infeaturestoaccommodatetheaccessneedsofpeo-ple with visual disabilities, those with hearing

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disabilities,thosewithmotordisabilities,andthosewith learning disabilities. This is especially true ofiPhones,Androids,andavarietyoftablets.Further-more,thereisrapidexpansionofactivitiesthatcanbe done using cell phones and smartphones. Forexample, more andmore commerce and bankingarebeingconductedusingthesemobiledevices.Recommendations for the mobile technologyindustry. Cell and smartphone designers andmanufacturers are encouraged to expand theirbuilt-inaccessibilityfeaturestoaddresstheneedsofpeople with complex communication needs whofrequently have multiple disabilities. Vision isalreadybeingaddressedviavoiceover,zoom,speakselection, larger text, contrast, andmore.Hearingand learning disabilities are also being addressed.Most relevant to individuals with complexcommunication needs is physical and motoraccessibility features, including switch control andassistive touch. As shown by the data from thisstudy, most people with complex communicationneeds have motor disabilities in addition to theirspeechdifficulties.Somealsohavelearning,visual,and hearing disabilities in addition to theirmotorandspeechdisabilities.Notonlymusttheseaccessfeatures be available on newmobile devices, butalso they must be widely marketed so familymembers or professionalswho serve and supportthis population know they exist. This is especiallycriticalbecauseresultsfromthisstudyindicatethatfamilymembersandprofessionals ineachcountryare the ones who most frequently recommendmobile devices to adults with complexcommunicationneeds.Recommendations for the assistive technologyindustry.ManufacturersofspecializedAACdevicesshouldconsiderexpandingtheirdesignsofsoftwareorappsthatcaneasilybedownloadedontotheplat-formsandoperatingsystemsthatareusedinmain-streammobiledevices.Mainstreammobiledevicesare more powerful and certainly more image-enhancingthancurrentspecializedspeechgenerat-ing devices. Specialized assistive communicationtechnologies, such as speech-generating devices,

haveratesofabandonmentashighas30%(Foley&Ferri,2012).Researchontherateofabandonmentof mainstream mobile devices by this populationcould yield important policy and clinical implica-tions.Recommendations for individuals with complexcommunication needs who use AAC. Individualswith complex communication needs who rely onAACwould benefit from learningmore about thebenefits of having access to and use of mobiletechnology suchascellphones, smartphones,andtablets. Without them, they will have feweropportunities for social interactions, communica-tionwithawidevarietyofindividualswithandwith-out disabilities, fewer opportunities for employ-mentandcommerce,lessaccesstoinformationandcommerce, and more. They should also becomemoreawareoftheaccessibilityfeaturesthatareal-readybuilt intoexistingmobiledevices,aswellasneededaccessibility features thatarepossiblebutremain absent in these mainstream devices. Thisinformationwill enable them to bewell-informedconsumers. Additionally, armed with this infor-mation they can become effective advocates inworking with policymakers at the local, national,andinternationallevels.

ConclusionsThe findings of this research suggest thatmost ofthe adults with complex communication needs intheUnited States and SouthAfrican sampleswhohaveaccesstoAACalsoownorusemainstreammo-biledevicesforavarietyofpurposesandtoengageinavarietyofactivities.However,forsome,useofthesedevicesisnoteasy.Furthermore,theburdenof adapting andmodifying their devices for easieruseisplacedontheperson,ratherthanbeingbuiltintothedevice,usingprinciplesofuniversaldesignordesignforall.Thissituationmustchangeifsocial,informational, and economic inclusion is to occur.ForcountriesthathaveratifiedtheCRPD,thereisameanstomonitor thecurrentsituation.TheCRPDcan also be used as an instrument for change (cf,G3ict&ITU,2012).Hopefullythisstudywillprovide

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people with complex communication needs andtheir advocateswithneeded information toeffec-tivelyadvocateforequalaccesstomobiletechnol-ogyinourever-growingdigitalworld.

DeclarationsThis content is solely the responsibility of the au-thorsanddoesnotnecessarilyrepresenttheofficialviews of ATIA. The authors disclosed a financialrelationshipwiththeNationalInstituteonDisabilityIndependentLivingandRehabilitationResearch.Nonon-financial disclosures were reported by theauthorsofthispaper.

Acknowledgements

ThisresearchwassupportedinpartbyagrantfromtheRehabilitationEngineeringResearchCenterforWirelessTechnologies(WirelessRERC).

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published by the assistive technology industry association (atia) · 2018-08-28 · volume 11,...

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