Case Study 1

Excerpted from "The Clinician's Guide to Assistive Technology" Computer Access Chapter by Jutta Treviranus and Linda Petty. Mosby Publishing, Inc. In publication

Application/Goal

The problem addressed by this application was to provide flexible computer access and equipment to meet the changing physical development and educational/ literacy/communication needs of a very young child with a congenital condition, Cerebral Palsy.

Function/Ability

Christopher was initially assessed for technology access in Dec. 1993, at the age of 4. Computer access recommendations were given to his community team for single switch programs to develop motor control and letter recognition. Further assessment and equipment trials in April 1994 resulted in the lease of a Macintosh LC II computer system with Ke:nx, several single switches and an expanded Unicorn keyboard and keyguard, Apple 11e emulator card and disk drive. Software included a Macintosh talking word processor, Intellitalk, Apple 11e early learning software such as Charlie Brown's ABCs, First Letter Fun, etc. Christopher's family and support workers were trained in running the system and programming overlays when the system was put in place in early June. The computer access was flexible, promoting concrete, direct upper extremity targeting for some software with limited targets and training scanning skills with hand targeting of single switches for other software packages. Christopher's motor control was affected by fluctuating muscle tone and reflexes; the flexible access promoted development of motor control while operating fun, age appropriate and educational software programs.

Other technology recommendations at that time were:

Re-assessment of physical access in April 1995 indicated increased muscle tone following a growth spurt, increased prominence of an Asymmetrical Tonic Neck reflex and increased athetosis affecting active movement patterns. Quantified computer access trials demonstrated to Christopher's parents and the support team the greater effectiveness of using a switch accessed with head rotation for critically timed access needs, such as scanning for face to face communication and letter input to the computer system. A Zygo lever switch and mount was added to his computer access set up and his computer was upgraded to a Macintosh Performa 580CD to give adequate RAM and CD ROM access for educational and reading programs. ClickIt software was added to the use of Ke:nx for single switch access to CD Roms, using programmable "hot spots".

Other technology recommendations included the use of a portable Apple Powerbook system with Speaking Dynamically, Boardmaker, ClickIt, Ke:nx and a talking word processor, Intellitalk, for use at school for face to face and written communication. This system was accessed with the lever switch to obtain the best possible speed and accuracy needed for scanning. As Christopher used the larger Armslot switch on his tray for driving, the Powerbook system was secured in it's place on his tray for in-class or in-home sessions only, rather than being available at all times. Christopher continued to use his communication book, eye gaze, etc. for immediate communication needs.

By the winter/spring of 1996, Christopher was demonstrating improved physical control, particularly of his right upper extremity. This was attributed to extensive driving practice with the arm-slot switch, maturation, excellent seating and therapy. A gated, center mounted joystick was introduced for driving, and after a training period, substituted for the Armslot switch. The new power chair access allowed for flexibility in mounting the portable computer system and new options for computer access using the joystick. Trials were next carried out with Direct Point computer access technology, where an interface allows the user to "drive" the computer cursor with the wheelchair control with a remote selection switch in summer 1996. This was successful, offering faster, more immediate access to face to face communication displays and an on-screen keyboard for computer access. The head switch was still used for selecting targets once the mouse pointer dwells over them, as this offered faster and more accurate than selecting with a timed dwell setting. As the Armslot switch was no longer positioned on the wheelchair tray, Christopher's portable computer system could be mounted with a modular bar and bracket to give him multiple work surfaces and more ready access to his portable system. The Direct Point is used to access both his stationary system for dedicated writing, literacy activities and the portable system for face to face communication and portable writing needs.

Considerations/Options

Technology is available to support even very young children with multiple disabilities, however, the funding and support systems need to be flexible to allow regular re-assessments and changes of equipment to suit changes in physical status and educational/communication needs. Integration, compatibility and overlap of training with systems used for communication and education need to be considered and promoted in choosing equipment.

Outcome/Social Validation

The computer access equipment described supported Christopher through very crucial formative years of development from ages 4 to 8, and from nursery school to Grade 2 in educational and communication content. The cost of the original computer system and access technology was approximately $3,000.00 USD, however, as Christopher had rapidly changing needs he was able to use a Province of Ontario leasing program. This provided flexibility and recycling of equipment as Christopher's needs for physical access and educational/communication material changed. As technology was also changing throughout this time, it supported the transition between the early use of Apple 11e software to Macintosh educational CD ROMs 2 years later. Costs of his later system of the DirectPoint, Performa 5800, etc. was approximately $3500.00 USD, with the access hardware being shared between the stationary and portable system. The changes in hardware, software and access methods were made following assessments or re-assessments which clearly demonstrated the gains in speed, accuracy and computer input and the compatibility needs of the school environment, which made the requests acceptable to the funding/leasing agency. The changes were done with thorough discussion and consultation with the family, school staff and support team, with documented rationale, resulting in full support by all concerned. The changes were also introduced sequentially, to prevent overwhelming the client and support system with new technology for computer, mobility and communication all at once. Christopher was able to access technology for age and grade appropriate written and face-to-face communication with a minimum of frustration due to his physical limitations. The uncounted costs of not providing this progressive access technology and support would have been behavioural problems due to frustration, limited literacy and communication skills and increasing dependence for any educational programming. In contrast, the client now can attend a regular school independently with some teaching assistance support for his equipment and full opportunities to participate in classroom and home learning opportunities.

Technology Resources

Macintosh computers: Apple Computers, Inc.

Ke:nx, single switches - alternative access interface for the Macintosh from Don Johnson, Inc.

1000 N Rand Rd, Bldg 115
PO Box 639
Wauconda IL USA 60084-0639
Phone:800-999-4660 USA & CANADA
847-526-2682 USA & GLOBAL
E-mail: djde@mcs.net
URL:http://www.donjohnston.com

intellitools

Unicorn keyboard, Intellitalk, ClickIt software: expanded keyboard and software from Intellitools Inc.

55 Leveroni Ct., Suite 9
Novato, CA 94949 USA
Phone: (415) 382-5959
Email :intellitoo@aol.com
URL: http://www.intellitools.com

Armslot Switch Controller:

DU-it control Systems Group Inc.

8765 Twp. Rd. 513,
Shreve Ohio 44676-9421 USA
(216) 567-2906

Speaking Dynamically, Boardmaker

Mayer-Johnson Co.
P.O.Box 1579
Solana Beach, CA 92075-1579
Tel: 619-550-0084 Fax: 619-550-0449
E-mail: MayerJ@aol.com
URL: http://www.mayerjohnson.com

Zygo Lever Switch:

Zygo Industries, Inc.
P.O. Box 1008
Portland OR 97207-1008
Tel: 800-234-6006 or 503-684-6006 Fax: 503-684-6011

Zygo Switch mounting:

David Cooper, Sunnyhill Health Centre for Children

3644 Slocan St.,
Vancouver, BC, V5M 3E8, CANADA
(604) 436-6527

Direct Point:

Jerzy Antczak, Bloorview MacMillan Centre

350 Rumsey Rd., Toronto, ON M4G 1R8, CANADA
(416) 425-6220
E-mail: ortcja@oise.utoronto.ca