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
FEATURE |
MACINTOSH |
WINDOWS PLATFORM |
Key Repetition Control
(Ignores brief or repeated keystrokes; slows repeat rate) |
The keyboard Control Panel can be manipulated to eliminate keystroke errors due to tremors. Open the Keyboard Control Panel; go to “Keyboard”; turn “Key Repetition” off | These features are included in Windows 2000 and XP software and turned on in the Control Panel. Open “Accessibility Options”; “Keyboard”; turn on “Filter Keys”; and press “Apply”
For Windows Vista, look under “control panel” and “ease of access”; “change how Keyboard works” and “turn on Key repetition control” |
Sticky Keys
(Single Key Typing – use Shift, Ctrl or Alt key by pressing one key at a time) |
Most Macintosh computers come with “Easy Access” in the Control Panel. Single Key typing can be turned on by opening “Easy Access” and then turning on “Sticky Keys” | These features are included in Windows software. Go to the Control Panel. Open “Accessibility Options”; go to “Keyboard”; turn on “Sticky keys”; press “Apply”
For Windows Vista, look under “control panel” then “ease of access”; “change how Keyboard works” and “turn on Sticky Keys” |
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
FEATURE |
MACINTOSH |
WINDOWS PLATFORM |
Enlarged Keyboard with Keyguard
*Keyguards need to be ordered separately |
1) Clevy Keyboard- enlarged color coded keys, does not include function keys, is PC and MAC compatible. Accessories include: keyguard and keyboard cover. Available at Ablenet,Inc., 800-322-0956 or online: www.ablenetinc.com
2) Kinderboard– large 1 inch square keys, color-coded character sets, includes function keys. Available at Boardmaker, 800-588-4548 or online at https://goboardmaker.com/ |
1) Clevy Keyboard- enlarged keys keyboard that is PC and MAC compatible. Accessories include keyguard and keyboard cover. Available at Ablenet Inc.,800-322-0956 or online: www.ablenetinc.com 2) Kinderboard– large 1 inch square keys, color-coded character sets, includes function keys. Available at Boardmaker, 800-588-4548 or online at https://goboardmaker.com/
|
Keyboard Layout
|
An alphabetically ordered keyboard is available for most enlarged or specialized keyboards, or on a standard keyboard via keyboard Zoom Cap “stickers” Available at Don Johnston, Inc., 800-999-4660 www.donjohnston.com | An alphabetically ordered keyboard is available for most enlarged or specialized keyboards, or on a standard keyboard via keyboard “stickers” Available at Don Johnston, Inc., 800-999-4660 www.donjohnston.com |
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
FEATURE |
MACINTOSH |
WINDOWS PLATFORM |
||||
Joystick | 1) Joystick Plus II by TRAXSYS: Allows for easy cursor speed adjustments as well as double click and latching drag feature. Has interchangeable handles. No additional software required. Available at Don Johnston, Inc.,800-999-4660) or online: www.donjohnston.com
2) Rock Adapted joystick- programmable right left buttons, drag-lock for one- handed click and drag operation. Available at Ablenet at 800-322-0956 or online @ www.ablenetinc.com |
1) Joystick Plus II by TRAXSYS: Allows for easy cursor speed adjustments as well as double click and latching drag feature. Has interchangeable handles. No additional software required. Available at Don Johnston, Inc., 800-999-4660 or online: www.donjohnston.com
2) Rock Adapted joystick- programmable right left buttons, drag-lock for one- handed click and drag operation. Available at Ablenet at 800-322-0956 or online @ www.ablenetinc.com |
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Arrow Keys | 1) Use arrow keys on an enlarged keyboard to control the mouse. (such as on The Intellikeys)
2) The numeric keypad on a standard keyboard can be used; need to hold-down the keys to operate movement; To convert to Arrow Keys go to the Control Panel, open “Easy Access”, “Mouse Keys”, “On” |
1) Use Arrow keys on an enlarged keyboard to control the mouse. (such as on the Intellikeys)
2) The numeric keypad on a standard keyboard can be used to control the mouse; Need to hold-down the keys to operate; To activate this feature go to the “Control Panel”, “Accessibility Options”, “Mouse”, click on “Use Mouse Keys”, “Apply”; Adjust speed of pointer in “Settings” menu. 3) For Windows Vista, “control pane;”; “ease of access”; “Make mouse easier to control”; and “turn on mouse keys.” |
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Trackball
|
1) Kensington Expert Mouse 7.0 This trackball comes with software, which provides latching drag and double click switches, as well as adjustable speeds. Additional software required (included). Available at Kensington, Inc. (650) 572-2700 www.kensington.com
2) Roller Plus – large ball with double click, latching drag, and variable cursor speed. No additional software required. By TRAXSYS; Available at Don Johnston, Inc. (800-999-4660) www.donjohnston.com 3) Wave Wireless switch adapted trackball, programmable left- and right-click buttons, drag-lock for one handed click and drag operation 4) Kidtrac, 2-button trackball, adjusts for right- and left- hand use, and has drag-lock feature. – –Available at Boardmaker, 800-588-4548 or online at https://goboardmaker.com/ |
1) Kensington Expert Mouse 7.0 This trackball comes with software, which provides latching drag and double click switches, as well as adjustable speeds. Additional software required (included). Available at Kensington, Inc. (650) 572-2700 www.kensington.com
2) Roller Plus – large ball with double click, latching drag, and variable cursor speed. No additional software required. By TRAXSYS; Available at Don Johnston, Inc. (800-999-4660) www.donjohnston.com 3) Wave Wireless switch adapted trackball, programmable left- and right-click buttons, drag-lock for one handed click and drag operation 4) Kidtrac, 2-button trackball, adjusts for right- and left- hand use, and has drag-lock feature. – –Available at Boardmaker, 800-588-4548 or online at https://goboardmaker.com/ |
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Keyboard Shortcuts may be used in place of a mouse when mouse control is particularly difficult. Use of the “Sticky Keys” feature, noted in the section above, is helpful when using keyboard shortcuts. “Sticky Keys” eliminates the need to hold down two keys simultaneously. | Spell Check [Command L]
Close Window [Command W] Open File [Command O] New File [Command N] Save [Command S] Print [Command P] Copy [Command C] Cut [Command X] Paste [Command V] Bold [Command B] Italicize [Command I ] Underline [Command U] Select All [Command A] Reduce Font [Command Shift < ] Enlarge Font [Command Shift > ] Undo [Command Z] Escape [Command .] Quit [Command Q] |
[F7] [Ctrl F4] [Ctrl O] [Ctrl N] [Ctrl S] [Ctrl P] [Ctrl C] [Ctrl X] [Ctrl V] [Ctrl B] [Ctrl I ] [Ctrl U] [Ctrl A] [Ctrl Shift < ] [Ctrl Shift >] [Ctrl Z] [Esc] [Alt F4] | ||||
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
FEATURE |
MACINTOSH |
WINDOWS PLATFORM |
Standard Monitor
|
A clear color display with good clarity and contrast is required. Standard monitor (15 – 17 inches) or laptop computer with active matrix color monitor | A clear color display with good clarity and contrast is required. Standard monitor (15 – 17 inches) or laptop computer with active matrix color monitor |
Enlarged Fonts
|
Specific size determined by testing | Specific size determined by testing |
Enlarged Mouse Cursor
|
1) Biggy: software to visually enlarge the mouse cursor. Available from R.J. Cooper & Associates 1-800-RJCooper www.rjcooper.com
2) On Mac OS x 10, Use Tiger’s Universal Access preference panel; go to “Mouse & Trackpad” settings to change your cursor size 3) Free cursor alternatives are also available on The Web by typing in “free enlarged mouse cursors” into a search engine |
1) Biggy: software to visually enlarge the mouse cursor. Available from R.J. Cooper & Associates 1-800-RJCooper www.rjcooper.com
2) Gus! Big Cursor: Visually enlarges the mouse cursor. Available for free from Gus! Communications , 360-715-8580 or online www.gusinc.com/computeraccess.html 3) Windows 2000 & XP have a mouse cursor enlargement feature that enlarges the cursor to some degree. Available in the Control Panel under “Mouse”; + “Pointers”; “Scheme” 4) For Windows Vista, look under “control panel” and “ease of access”, “change how Mouse works,” under “mouse pointers” change color and size to select Extra Large (choose from black, white or inverting) 5) Free cursor alternatives are also available on The Web by typing in “free enlarged mouse cursors” into a search engine |
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
FEATURE |
MACINTOSH |
WINDOWS PLATFORM |
Auditory Feedback of Keystrokes And Written Work
|
1) Word Q- Talking word prediction software that is used along with standard Windows word processing software including spoken text-to-speech feedback. Can also serve as a screen reader. Available at www.wordq.com or 800-726-7784. Free 30 day trial available.
2) Write:OutLoud – talking word processor (hear letters, words, or sentences while you type) with talking spell check. Able to “read” scanned documents; by Don Johnston, Inc. (800-999-4660) www.donjohnston.com 3) Read & Write Gold for MAC – simplified version available for MAC (See Right); by textHELP www.texthelp.com
|
1) Word Q- Talking word prediction software that is used along with standard Windows word processing software including spoken text-to-speech feedback. Can also serve as a screen reader. Available at www.wordq.com or 800-726-7784. Free 30 day trial is available.
2) Write:OutLoud – talking word processor (hear letters, words, or sentences while you type) with talking spell check. Able to “read” scanned documents; by Don Johnston, Inc. (800-999-4660) www.donjohnston.com 3) Read & Write Gold for PC – use with any word processor; talking spell check, homonym support, thesaurus, word prediction, instant speech feedback, screen reading (including menus, e-mail and internet) TextHelp www.texthelp.com |
Word Prediction
|
1)Word Q- Talking word prediction software that is used along with standard Windows word processing software including spoken text-to-speech feedback. Available at www.wordq.com or 800-726-7784. Free 30 day trial is recommended before ordering
2) Co:Writer – Talking word prediction software intended to save Keystrokes; Don Johnston 800-999-4660 www.donjohnston.com 3) Read & Write Gold for MAC multifunction software containing talking word prediction – textHELP www.texthelp.com
|
1)Word Q- Talking word prediction software that is used along with standard Windows word processing software including spoken text-to-speech feedback. Available at www.wordq.com or 800-726-7784. Free 30 day trial is recommended before ordering
2)Co:Writer – Talking word prediction software intended to save Keystrokes; Don Johnston 800-999-4660 www.donjohnston.com 3) Read & Write Gold –multifunction software containing talking word prediction – textHELP www.texthelp.com |
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
FEATURE |
MACINTOSH |
WINDOWS PLATFORM |
Optical Character Recognition (OCR) software | 1) Kurzweil 3000 for Macintosh- Provides auditory and visual presentation of scanned text and images; Able to read Internet documents; Designed for student and adult users. Available at 800.894.5374 or online: www.kurzweiledu.com. A free trial is available
2) WYNN 5.1 – Not available for MAC 3) Read & Write Gold for MAC- – use in conjunction with any word processor; also for spread sheets, desktop publishing, databases, e-mail and Internet; color highlighting of words and sentences; button to pause/ resume speech – from textHELP www.texthelp.com |
1) Kurzweil 3000 USB – PC based reading system; Provides auditory and visual presentation of scanned text and images; Able to read Internet documents; Designed for student and adult users. A free trial is available at 800.894.5374 x603 or online: www.kurzweiledu.com.
2)WYNN Wizard 5.1 – provides auditory and visual presentation; Scanned pages retain original page layout; Designed especially for students with learning disabilities; Available at 800-444-4443, or online: www.freedomscientific.com 3) Read & Write – use in conjunction with any word processor; also for spread sheets, desktop publishing, databases, e-mail and Internet; color highlighting of words and sentences; button to pause/ resume speech – from textHELP www.texthelp.com |
Screen Reading Software
|
1) Mac OS X version 10.4 “Tiger”- VoiceOver feature reads aloud the contents of files including web pages, Mail messages and word processing files, provides a comprehensive audible description of your workspace and includes a rich set of keyboard commands that allow you to navigate the Mac OS X interface and interact with application and system controls.
2) Word Q- Talking word prediction software that is used along with standard Windows word processing software including spoken text-to-speech feedback. Can also serve as a screen reader. Available at www.wordq.com or 800-726-7784. Free 30 day trial is recommended before ordering
|
1) Microsoft windows Vista now includes a screen reader called Microsoft narrator. To activate the screen reader, go to “Control Panel”; select “Ease of Access”; select “Make computer easier to see”; and “Turn on narrator.”
2) Word Q- Talking word prediction software that is used along with standard Windows word processing software including spoken text-to-speech feedback. Can also serve as a screen reader. Available at www.wordq.com or 800-726-7784. Free 30 day trial is recommended before ordering
|
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.