Chapter 15: Assistive Technology for Written Communication

Rev. 2008; originally published 2000

ASSISTIVE TECHNOLOGY FOR WRITTEN COMMUNICATION

Loreta McPartland, Lynnley Moore, Nancy Inman 

Reports, spelling lists, journals, and exams are daily activities in the life of a typical student. Yet for the patient with A-T, these simple tasks are much more difficult. Problems with legibility, time restrictions, and fatigue are common and adversely affect the ability of these students to participate in class and to demonstrate what they have learned. Adapted pencils and slant boards do not typically ease fatigue or improve the speed and legibility of handwriting. Scribes, although a favorite among students, may hinder the student from learning spelling, punctuation, capitalization, and organization of thoughts. To provide greater independence and continued educational growth, an adapted computer is often an effective assistive technology tool for the A-T patient.

Computers, too, have their limitations. Logistics of multiple classrooms, cost, and time restrictions continue to be a problem. However, the evolution of portable computers, scanners, highly adaptable hardware and software, and the World Wide Web have made computer access easier and an overall benefit for the A-T patient.

The Evaluation Process

The primary focus of the Assistive Technology evaluation is computer access and use. Keyboard access, mouse control, visual ability, and reading needs are explored. The evaluation process begins with an assessment of the patient’s home, school or work requirements, as well as current reading and writing skills. Information regarding the benefits and obstacles associated with currently used assistive devices such as altered writing surfaces or adapted computer access is gathered. Legibility, fatigue, and speed of writing are evaluated (very young children may be observed while drawing a picture). Next, the patient is provided with a standard computer and monitor. Visual ability is informally assessed to establish a comfortable font size for reading text. Typing trials are performed while manipulating hardware and software to find those combinations that optimize speed, accuracy, comfort, and quality of output. Software to enhance reading skills is then also reviewed.

General Findings

The typical patient with A-T has difficulty with eye movements, fine motor coordination of the hands, and trunk control. Together, these deficits create difficulty for completing reading and writing tasks. Visual tracking is also often a factor adversely affecting reading ability. Many patients function below grade and age expectations in the area of written communication in part because of poor legibility and slow writing and typing speeds. Sometimes patients are reluctant even to attempt a writing task because of the required effort and modest results. Many patients with A-T have been encouraged to type as an alternative to handwriting. However, unless adaptations have been made to the standard computer and keyboard, the results are often discouraging. The use of an aide to act as a scribe, although efficient, often encourages dependence upon others. Fortunately, it has been found that computer access may be quite beneficial when appropriate accommodations are made.

Recommendations

Although general guidelines for hardware and software can be made, specific recommendations are dependent on age, skill level, requirements for written communication and experience. A skills assessment by a specialist, and trials of hardware and software are highly recommended before purchases are made. (Be sure to specify whether purchases will be used with a Macintosh or Windows platform computer.)

Seating and Positioning For Computer Activities

Stability in a chair is a prerequisite to success with a computer. The student’s feet need to be flat on the floor or fully supported, the pelvis and trunk touching and supported by the back of the seat, and elbows and forearms resting on the desktop without extending outward or leaning forward. Elbows should rest at a 90-degree angle with wrists flat. A U-shaped cutout table is an excellent way to facilitate this appropriate position of the upper extremities. “Rifton” adapted chairs and multidesks are often recommended (1-800-571-8198 or online: http://www.rifton.com/index.html), but other chairs with side-arms  and tables can also be used. Individuals with excessive involuntary movements may benefit from an adapted seating system with a seat belt to help hold the pelvis, trunk and head stable. The top of the monitor should be at the height of the forehead and should be approximately two feet away from the eyes.

Computer Keyboard Adaptations

Simple adaptations can be made within the computer’s control panel to facilitate use of a standard keyboard. Unintended duplications of the same letter can be decreased by adjusting the “Key Repetition Control.” If the patient types with one hand and it is difficult to hold down two keys simultaneously, the “Sticky Keys” function may be helpful. Using this feature allows the user to access commands such as capital letters and keyboard shortcuts by pressing one key at a time instead of two simultaneously. For example, when trying to type a capital letter, the user types [Shift] then the target letter, one after the other. The target letter will appear in uppercase and the next letter typed will automatically appear in lowercase. This is more efficient than using the [Caps Lock] key, because it eliminates the need for an additional keystroke to turn [Caps Lock] “off”.

Table 1: Adaptations for Standard Keyboards

For students who use a standard keyboard but have difficulty seeing the keys, adhesive labels called ZoomCaps may be purchased. The letters, numbers, and symbols are enlarged and use the American Printing House for the Blind, APHont™ for easier viewing by individuals with low vision. Labels are available in black on white and white on black and include all keycaps for Windows and Macintosh keyboards. They may be purchased from Don Johnston Corporation by calling 800-999-4660 or at www.donjohnston.com.

Most patients with A-T will eventually benefit from an enlarged keyboard, providing improved stability, control and thus accuracy. The most useful enlarged keyboards have adjustable sensitivity to touch, mouse control options, multiple keyboard configurations, optional keyguards, and comfort in design. The Intellikeys USB keyboard, for example, plugs directly into the computer’s USB port. It is an enlarged keyboard that uses overlays over a programmable surface to create a variety of keyboard and mouse options.  For younger children who do not need adjustable sensitivity and mouse control options, color-coded enlarged keyboards such as the KinderBoard, by Chester Creek Technologies, and the Clevy Keyboard, sold by Ablenet Inc. may also be considered. Keyguards for these specialized keyboards are available and must be ordered separately.

Prices for recommended enlarged keyboards range from $100 to $500, and keyguards generally add an additional $100. Special package rates may be available.

Keyboard layout (ABC vs. QWERTY) generally depends on user preference, literacy level, and past experience. Children who are just learning the alphabet may prefer the ABC layout, while students with past computer experience may prefer the standard QWERTY design.  QWERTY design keyboards are the standard keyboard used in most education settings.

A keyguard is another useful keyboard adaptation. A keyguard is generally made of metal or sturdy plastic and is cut to allow access to the keys. Its purpose is to help minimize typing errors due to extraneous hand movements. It also allows the user to comfortably rest the hands on the keyboard without triggering unwanted keystrokes. Although keyguards on specialized keyboards are often helpful, a keyguard on a standard computer keyboard is usually not recommended as it may hamper both access and ability to see the keys.

Although families and therapists have inquired about other forms of keyboard access, in our experience, none have been as effective as an enlarged keyboard. An onscreen keyboard displayed on the computer monitor and accessed via a joystick is generally slower. A computer touch screen is not recommended for patients with A-T due to the requirement for eye-hand coordination and the demands of reaching against gravity. Voice recognition software is also generally not recommended because of the dysarthria, or speech patterns, many A-T patients have.

Table 2: Enlarged Keyboards and Keyguards

Computer Mouse Control Options

Patients with A-T often complain about difficulty controlling a standard mouse, especially double clicking required for opening files and using the “drag” function. Alternative control devices that provide one touch access for double-click, locking-drag features, and are adjustable for speed of the cursor movement are often recommended instead.

Table 3: Computer Mouse Control Options

We have found that many patients with A-T are most successful using the arrow keys on the Intellikeys USB  or a joystick because of their stable base and easily adjustable controls. If a patient is successfully using a different device, there is no reason to change. However, these devices should be considered for first-time computer users, or if difficulties arise with an alternative device. Personal preference and past experiences play an important role in final recommendations. Prices for alternative mouse control devices range from $30 to $500.

Computer Visual Adaptations

Visual abilities are often overlooked during computer and writing assessments; however, due to tracking problems, this is an important feature to assess. The A-T patient generally needs to have all written text enlarged, including text on the computer screen. This can be done quickly and easily by enlarging the font size on the computer either from the tool bar or by going to “Format” and “Font” when using Windows. Before printing, the font can be changed to a standard size by going to “Edit” then “Select All” and changing the font size. The degree of enlargement is determined on a case-by-case basis. Screen enlarging software, which enlarges the entire viewing area, is not recommended because of the difficulty it creates in tracking the text that has now been moved out of the viewing area. Enlarging the font size does not create the same problem.

Table 4: Computer Visual Adaptations

Enlarging the mouse cursor is also helpful for tracking the location of the mouse on the screen. Enlarged cursors are available on most computers via the “Control Panel,” through additional software, or downloaded for free from certain websites. Prices of cursor enlarging software generally start at $100.

Writing Technology

Auditory feedback software can be set to “speak” letters, words, or whole sentences. This can increase the typing speed of most A-T patients by eliminating the need for the novice typist to look continuously from the keyboard to the monitor in order to check what had been typed. A talking “spell check” feature is also available. Programs such as IntelliTalk and Write:Outloud are talking word processing programs, while Word Q and Read & Write are talking software that can be used within any software application (including e-mail and the Internet).

Word prediction has been found to be beneficial for the more proficient typist because it requires the user to watch the monitor while words are “predicted” on the screen in list format. The typist may then choose a word from the predicted list by either using a pointing device (joystick) or by typing the corresponding number key. Although word prediction is intended to reduce keystrokes, this tool has not been found consistently helpful in A-T patients. It requires that the users constantly shift their gaze from keyboard to monitor, and good visual tracking is necessary to quickly read the ever-changing word list. Prices for specialized software range from $100 to over $1,000.

For more information regarding general software for academics or leisure activities, Educational Resources (800-624-2926 or www.edresources.com) is a good source. Final selection of software should always be based on the user’s skill level and writing needs.

Table 5: Writing Technology

Reading Technology

Many patients with A-T have difficulty reading written text. Technology through Recording for the Blind (800-221-4792). More recently, computer software has been developed to “read” targeted text and screen menus. “Screen Reading Software” is generally designed for individuals who are blind or have very low vision. “Optical Character Recognition” (OCR) software is designed for individuals with reading difficulty due to low vision and/or a learning disability. Requirements generally include a Pentium class computer, sound card and supported scanner. To use an OCR, simply place the printed text (i.e. book, magazine, worksheet) on the scanner. The scanner takes a “picture” of the page. The software translates that picture back to words, then reads those words aloud. The user can generally control the size, color, and speed of the text being read. Some programs provide more features than others, although these added features generally increase the final cost of the product. For instance, reading text in email and on the internet is a new feature of many of these systems and is reflected in the price. Prices for OCR software generally start at $1,000. Demonstration disks are available from most manufacturers free of charge. Final selection of software should be made on a case-by-case basis, assessing the severity and type of reading disability as well as reading requirements (what will the software primarily be used for – academics, leisure, internet access, etc.).

Table 5: Writing Technology

Final Note

No matter what combination of computer hardware and software an individual is using, several important factors are important to keep in mind. First, the student and staff working with the student need to be familiar with the software and equipment so that valuable class time is not wasted reading manuals and setting up the equipment. Second, compatibility with computers in other classrooms and at home may need to be considered if work will need to be finished in a different setting. Last, an easily accessible printer is important to maintain an efficient work environment. This also gives the student the opportunity to present a final product that reinforces a sense of pride in what has been accomplished.

In addition to computer access, the patient with A-T will likely require other accommodations as well. These may include a reduction in workload, increased time to complete tasks, and a scribe to assist with lengthy writing tasks. In the latter situation, it is often recommended that the scribe use the computer when taking dictation, so that the student can then independently edit and reorganize the document.

Additional Resources

For more information, Closing the Gap is an Assistive Technology Resource Site that offers online resources, product reviews and it publishes a quarterly newspaper that addresses educational and vocational computer technology issues for individuals with disabilities. Each issue has reviews of new software programs and articles on new hardware technology. An annual “Resource Directory” of hundreds of hardware and software products is included with a subscription. The organization also holds an annual conference with hundreds of vendor demonstrations and informative lectures by professionals working in the field of Assistive Technology. Contact CTG at 526 Main Street, P.O. Box 68, Henderson MN 56044 or www.closingthegap.com.

Disclaimer: The information provided on this website should NOT be used as a substitute for seeking professional medical diagnosis, treatment or care. You should not rely on any information in these pages to replace consultations with qualified health professionals.