assistive technologies for cognitive disabilitiessg94g745/pubs/critrevin pmr... · i. assistive...

0896-2960/05/$35.00© 2005 by Begell House, Inc.

Critical Reviews™ in Physical and Rehabilitation Medicine, 17(3):195–215 (2005)

195

I. ASSISTIVE TECHNOLOGIES FORCOGNITIVE DISABILITIES

The combined prevalence of all individuals livingwith cognitive disability in the United States is 20million or about 7% of the population.1 Cognitivedisabilities are clinically complex—each havingunique effects on an individual that often changeover time, sometimes rapidly. Diagnoses that havecognitive disability as a primary characteristic in-clude the following:

• Acquired medical conditions, such as trau-matic brain injury (TBI), stroke /aneurysm,brain cancer, and anoxia. According to theBrain Injury Association, the prevalence oftraumatic brain injury alone is approximately

5.3 million across all ages, with an annualincidence of 1.5 million.2

• Brain deterioration related to progressivedisease processes (eg, Multiple Sclerosis,Alzheimer’s Disease, and other dementingillnesses).

• Learning and intellectual disabilities, oftenassociated with developmental disabilities suchas attention deficit disorder/attention deficithyperactivity disorder, mental retardation,autism spectrum disorders.

• Chronic and severe mental illnesses, such asschizophrenia.

Some cognitive disabilities are transient andrelatively mild, affecting only one or two areas offunction. Others, however, require intervention

Assistive Technologies forCognitive Disabilities

Marcia J. Scherer, PhD, MPH,1,* Tessa Hart, PhD,2 Ned Kirsch, PhD,3& Maria Schulthesis, PhD4

1Institute for Matching Person & Technology, Webster, NY, and Physical Medicine andRehabilitation, University of Rochester Medical Center, Rochester, NY; 2Moss RehabilitationResearch Institute and Department of Rehabilitation Medicine, Jefferson Medical College,Philadelphia, PA; 3Department of Physical Medicine and Rehabilitation, University of MichiganHealth Systems, Ann Arbor, MI; 4Drexel University, Department of Psychology and School ofBiomedical Engineering, Science and Health Systems

* Address all correspondence to Marcia J. Scherer, PhD, MPH, Institute for Matching Person & Technology, 486 Lake Road,Webster, NY 14580; Tel./Fax: 585-671-3461; email: [email protected]

ABSTRACT: Purpose: To provide a comprehensive review of assistive technology (AT) to offset cognitiveimpairment, including examples, with pros and cons and important considerations for AT selection. Method: Priorresearch and a literature review identified the critical need for a means to identify key elements known to influencethe successful use of AT and other supports by persons with cognitive disabilities. Results: The components ofeffective and satisfied AT use result from a good match among device features, user goals and preferences, andenvironmental resources (including trained professionals and providers). Conclusions: As the number of AToptions increase, individualized interventions for individuals with cognitive disabilities will be easier to accomplish.The key to successful and optimal use of these products will be a comprehensive yet individualized determinationof consumer needs and preferences and the identification of additional accommodations and supports.

KEY WORDS: assessment, assistive devices, brain injuries, cognitive disabilities, cognitive orthoses, cognitiverehabilitation, functional capabilities, neurorehabilitation, outcomes research, technology

Begell House Inc., http://begellhouse.com Downloaded 2006-1-5 from IP 69.204.86.169 by Prof. Marcia J scherer (Scherer)

196 Critical Reviews™ in Physical & Rehabilitation Medicine

for significant, long-lasting deficits in areas such asattention, learning and memory, and planning thathave a direct impact on daily functioning. Cogni-tive deficits affecting memory and organizationthat typically follow moderate and severe TBI, forexample, include difficulties with prospectivememory, recall of everyday events, and learningnew information.3,4 These difficulties affect a widerange of everyday activities and relationships, re-sulting in reduced participation in social/vocationalactivities and loss of personal independence.5,6

Cognitive interventions may also need to takeinto account multiple areas of functioning becauseof interactions among deficit areas. For someindividuals, physical difficulty may have an impacton cognitive efficiency. For example, focusingone’s attention exclusively on performance of aphysical task that is very demanding, such aswalking with an ataxic gait, may result in distrac-tion from a cognitive task, such as attending tovehicles approaching from the left. In such cases,a cognitive intervention may be of most value ifit is offered at a time when the likelihood ofdistraction associated with physical tasks is mostlikely to occur (eg, community ambulation), but itmay not be needed at other times (eg, watchingtelevision), when the demanding physical activityis not required. Conversely, for other individuals,difficulty with sustained memory or attention mayhave an impact on performance of tasks thatemphasize use of otherwise intact motor or sen-sory systems. For example, an individual withmemory impairments may suddenly experienceincreased accidents at work when faced with newtasks that are difficult to learn, or an individualwith attentional deficits may become unaccept-ably messy during meals, despite intact upperextremity functioning, when the dining room istoo noisy. In such cases, an assistive technology forcognition (ATC) intervention may be most usefulif it provides cues about how best to perform themotor tasks, rather than offering cues that aredirected at the cognitive impairment itself (eg,“when installing the large bolt, remember to keepyour left hand under the work bench”). Otherfactors, such as fatigue, pain, and depression, mayexacerbate difficulties in the above areas or beexacerbated by a person’s recognition of cognitivechanges. And, of course, each person with a cog-nitive disability is an individual with a unique

combination of needs, preferences, emotional re-actions, and support system. Given this compli-cated picture, it is crucial that rehabilitation pro-viders understand how to work with the individualwith cognitive disability to assess both strengthsand weaknesses, and to devise an optimal balanceof supports and accommodations that have beencustomized to the individual’s needs.7–9

The purpose of this article is to discuss someconceptual frameworks that may be useful fordeveloping or prescribing assistive technologies(AT) to offset cognitive disabilities, and to de-scribe some of the newer cognitive AT methodsthat have appeared in recent clinical and researchliterature. It is beyond our scope to consider alltypes of cognitive disability in this discussion or toexplore the entire universe of AT as it relates tocognitive disability. We have selected particularareas within the current authors’ expertise andhope that the points we draw will be applicable, aswell, to other areas. In the discussion that follows,most of our attention is devoted to the use ofcognitive AT within a rehabilitation context, whichmeans cognitive AT mainly for acquired disordersand mainly for adults. We begin with a generaldiscussion of intervention approaches, AT, anddisability, in general, and then move to specificdiscussions of research and practice related to ATfor cognitive disabilities.

II. INTERVENTIONS FORCOGNITIVE DISABILITIES

Because of the central importance of cognition foradaptive functioning in the home, school, andcommunity, cognitive disabilities are specificallytargeted in most comprehensive rehabilitationprograms. Although clinical interventions for cog-nitive problems are in wide use, actual evidence fortheir effectiveness constitutes a work in progress.Cicerone and colleagues10 did a literature review ofstudies reporting the result of interventions forcognitive disabilities due to TBI or stroke anddetermined that specific recommendations can bemade for remediation of language and perceptionafter left and right hemisphere stroke, respec-tively, and for the remediation of attention,memory, functional communication, and execu-tive functioning after TBI. More recent research


Volume 17 Issue 3 197

by Cicerone and colleagues11 has judged intensive,holistic, cognitive rehabilitation to be an effectiveform of rehabilitation, particularly for personswith TBI who have previously been unable toresume community functioning despite standardneurorehabilitation. The authors further concludethat perceived self-efficacy may have significantimpact on functional outcomes after TBI rehabili-tation and that measures of social participationand subjective well-being appear to represent dis-tinct and separable rehabilitation outcomes afterTBI. Given the importance of self-efficacy, thecontrol and independence offered by assistive tech-nologies have the potential to positively affect therehabilitation outcomes of social participation andsubjective well-being. Thus, the findings reportedabove support the belief that persons with cogni-tive disabilities require and can benefit from anumber of supports, many of which can be pro-vided by assistive technologies and adapted com-puter technologies.

In summary, by enabling a person to performdesired tasks, it is possible that assistive technolo-gies may provide a sense of competence andreconnection to the community. By accommodat-ing a person’s weaknesses and supporting his or herstrengths, assistive technologies can reduce psy-chosocial stressors, thus leading to renewed confi-dence, self-efficacy, and self-esteem.7,12

III. AT AND AT FOR COGNITION

In the United States, assistive technology was firstdefined in the 1988 Technology-Related Assis-tance for Individuals with Disabilities Act (or TechAct, PL 100-407), which was reauthorized in 1998(as PL 105-220) as the Assistive Technology Actand reauthorized again in 2004 (PL 108-364)

Any item, piece of equipment, or product system, whetheracquired commercially off the shelf, modified, or custom-ized, that is used to increase, maintain, or improve functionalcapabilities of individuals with disabilities.

As implied by the name, ATC is a specialsubclass of interventions that is designed to “in-crease, maintain, or improve functional capabili-ties” for individuals whose cognitive changes limittheir effective participation in daily activities.

Broadly defined, assistive technology for cogni-tion could refer to very familiar, basic devices usedby people with and without disabilities to supportmemory, organization or other cognitive func-tions, such as planner books, calendars, wrist-watches, and shopping lists. Simple and low-costdevices such as magnifying lenses, index cards, andtimers/alarm clocks and even cell phones canpromote independence and improve the individual’squality of life.13–15 As discussed in more detailbelow, there are also specialized devices that usecomputer software and networking capabilities tooffer much more sophisticated support to thecognitively impaired user. These newer, speciallydesigned ATC devices have features that can (1)maintain, organize, and facilitate access to infor-mation; (2) present suggestions, instructions, orcorrections to the user—either on demand or atprescribed times; (3) assume responsibility for taskcomponents that have proven too complex for anindividual to complete independently, so thatactivities in which those components are embed-ded can be successfully completed; (4) providemore comprehensive interactive guidance for tasksthat are too difficult for the user to initiate orperform, even with other types of modificationsand compensatory strategies; and (5) monitor thequality of the user’s task performance so that errorscan be tracked and the ATC intervention subse-quently modified in an attempt to reduce thoseerrors. Regardless of the sophistication of thedevice, the primary clinical goal of ATC interven-tions is to improve performance of functionalactivities that are critical components of indepen-dent community life, that contribute substantiallyto quality of life, or that significantly reducecaregiver burden.

In the World Health Organization’s Interna-tional Classification of Functioning, Disability andHealth (ICF),16 assistive technologies are consi-dered to be an environmental factor. Other environ-mental factors are shown in Table 1. These includesupport from other persons, including the psycho-social factors of cultural and attitudinal influenceson the part of those persons; accommodations tothe built, physical, architectural space; and thecharacteristics of the available services available topersons with disabilities. Environmental factors caninclude access to healthcare and rehabilitation,access to AT and personal assistance, and access to



information. Environmental factors are assumedto have downstream effects on the ICF domainsof body functions, activities, and participation.

Accommodations in the built or natural envi-ronment, public areas, and work sites; appropriatehealth care; available personal assistance; and ac-cessible forms of information are all key resourcesessential for persons with disabilities to participatein society and fulfill desired social roles. Addition-ally, for individuals having cognitive difficulties,barriers may be more subtle or not as readilyappreciated by the community. For these indi-viduals, limitations of the cognitive/informationalcomponents of the built environment may repre-sent far more significant barriers to accessibility(eg, highway signs that are confusing or inconsis-tently color coded, store and marquee signs thatdon’t clearly communicate the product being sold,insufficient maps and informational kiosks at largeshopping malls). As noted in the discussion sec-tion below, growing recognition of these cognitivebarriers will become increasingly important aspersons with cognitive disabilities return to com-munity life. Because assistive technology is in-tended to facilitate health and functioning, lack ofresources to find or purchase AT constitutes anenvironmental barrier. A lack of trained personnelto assist in choosing and obtaining AT also con-stitutes a barrier within the social environment (as

do policies that set a low priority on resourceallocation for AT). The failure of a service pro-vider to require that personnel conduct a compre-hensive assessment of consumer needs and priori-ties, abilities related to the use of AT, and ATpreferences at the beginning of the AT and sup-port selection process is also a barrier.

IV. SPECIFIC AT DEVICES FORCOGNITIVE DISABILITY

Two broad areas of function with which individu-als with cognitive disabilities often need assistanceare memory and organization. A variety of tech-niques and devices have long been used for sup-porting these abilities, including “low-tech” de-vices such as written lists, notebooks, and planners.With training and rigorous practice and use, writ-ten strategies can help persons to remember dailytasks and routines more effectively.17 For exam-ple, a randomized control trial showed that exten-sive, systematic group training in notetaking strat-egies resulted in fewer self-rated everyday memoryfailures, compared to a “sham” group therapyfocused on general problem-solving abilities.18

Although a variety of written strategies such asnotebooks, planners, and lists are in widespreaduse in rehabilitation programs, training in how to

TABLE 1ICF Environmental Factors

Products and technology: Any product, instrument, equipment, or technology adapted or specially designed forimproving the functioning of a disabled person and to enable the ICF domain of activities.

Natural environment and human-made changes to environment: Animate and inanimate elements of the naturalor physical environment, and components of that environment that have been modified by people, as well ascharacteristics of human populations within that environment.

Support and relationships: People or animals that provide practical physical or emotional support—nurturing,protection, assistance, and relationships—in the home or place of work, at school or at play, or in other aspectsof daily activities.

Attitudes: Attitudes that are the observable consequences of customs, practices, ideologies, values, norms,factual beliefs, and religious beliefs.

Services, systems, and policies: Services that provide benefits, structured programs and operations in varioussectors of society and are designed to meet the needs of individuals. (Included in services are the people whoprovide them.)



use them is typically conducted with a less system-atic approach than in a research protocol,19,20 andthis results in varied proficiency in and satisfactionwith their use.

Despite their popularity as assistive devices,paper memory and organizational systems havecertain drawbacks for those with cognitive dis-abilities. Paradoxically, the very deficits that anotebook is designed to remediate may make ithard for the user to implement the strategy, andthere is evidence that training on written compen-satory strategies is most effective for people whosecognitive impairments are not severe.10,21 That is,it may require memory, executive function, andbehavioral self-regulation to keep track of a note-book and to initiate its use at appropriate times22—all of which are typically challenging for thosewith more severe forms of cognitive disability.Users may learn to record appointments in aplanner but still miss them by failing to consultthe book in time. Thus, the person with cognitivedisability may remain dependent on therapists andfamily members for continual reminders to “useyour book.” Recognizing this difficulty, Kirschand colleagues23 developed an intervention usinga generic system similar to NeuroPage that pro-vided cues for making entries in a standard memorybook. The study participant, an individual with ahistory of both TBI and resected intracranialtumor, substantially increased his reliable use of amemory log in response to these cues.

Another drawback is that memory notebooksmay also be too cumbersome for some work envi-ronments or other situations where space is at apremium. Partly because they tend to be obtrusive,paper reminder systems such as notebooks andclipboards are resisted by some consumers as stig-matizing.24 Additionally, there are important lifeactivities or treatment goals for which writtenstrategies do not readily apply. These include, forexample, recalling information that is processedduring a conversation, or remembering to engagein a specific adaptive behavior that must be re-peated throughout the day, often at unpredictabletimes. In a recent study by Hart and colleagues,25

persons with cognitive disability due to TBI wereasked what strategies they used to handle 10everyday tasks requiring memory and organiza-tion and whether their strategies were successful.Strategies were analyzed by task, success rate, and

type of approach (eg, internal or external; system-atic or haphazard). Substantial differences ap-peared across tasks in the types of strategies thatpeople found to be effective. For example, “re-membering things to do” was reportedly a difficulttask for many respondents. This task was found tobe performed more successfully with an externalversus internal strategy, whether systematic ornot. Using a list in a planner book, or a list jottedon a scrap of paper, were both reported to beeffective. However, for the task of “rememberingthings people tell you,” success was relatively lowregardless of strategy type, and no respondentsreported using a systematic external strategy forthis task. This result was consistent with previousfindings suggesting that recall of important orallypresented information is less amenable to pencil-and-paper compensatory strategy training thansome other types of information, such as dailyactivities or to-do lists.4

As noted previously, alternatives to paper-based supports now exist in the form of a varietyof technological supports. In the 1980s, whendesktop computers entered widespread use, severalresearch programs began to explore the potentialuses of computers for people with cognitive dis-abilities. The work of Glisky, Schacter, and col-leagues26–28 showed that patients with severelyimpaired anterograde memory were capable oflearning word processing and other computer skillsvia programmed instruction on a desktop com-puter, with gradually fading cues. In another earlyeffort, Kirsch and colleagues29 developed cueingsoftware known as interactive task guidance (ITG).In one application, ITG software was installed ona desktop computer that was housed on a rollingcart and taken along a janitorial route. The pro-gram guided brain-injured employees through theirjanitorial work routines with greater success com-pared to traditional note-taking strategies.30 Al-though this system was mobile, computers of theera were too large to be truly portable assistivedevices. That is, they could not be carried with theperson into a range of settings and applications.As computers have become small and portable, ithas been possible to conceive of wearable “cogni-tive orthoses.” Electronic devices such as personaldigital assistants (PDAs), pocket-sized computers,software-driven paging systems, and program-mable wristwatches are gaining clinical use in



rehabilitation programs and have been studied incontrolled investigations within the last few years.A series of studies has demonstrated that a pro-grammable paging system called the NeuroPagecan help persons with brain injury keep appoint-ments and complete other prospective assign-ments more independently.31–33 The NeuroPageis an alpha-numeric beeper that sends pre-pro-grammed reminder messages at set times. Thus,using it requires minimal learning compared to“mainstream” devices such as hand-held PDAs.

In a recent study by Wade and Troy,15 fivepersons with TBI were provided with mobilephones that notified them of tasks to accomplishat specific times during a 12-week trial. Subjectsor their caregivers kept diaries before, during, andafter this period to select target goals and gaugethe success of the phone reminders. All subjectsreportedly achieved 100% success with time-linkedactivities such as taking medications. In anotherstudy, also using five respondents who kept perfor-mance diaries at home, van den Broek and col-leagues34 trained the respondents to use portablevoice organizers to record messages and remindersabout household tasks to perform, in the user’sown voice. Improvement in the target tasks wasreported for each case. Similarly, Yasuda and co-workers35 used a voice recorder to prompt personswith memory impairments to complete a varietyof household tasks. Performance reportedly im-proved for five of the eight participants.

Portable electronic devices have also beenused with success in populations with develop-mental cognitive disabilities. For example, a pocketPC with specialized scheduling software was shownto help persons with mental retardation performvocational tasks, both more independently and ina more timely fashion.36

Most of the studies discussed above focused onproviding automated alarms for time-linked tasks,such as taking medications or keeping therapyappointments. Hart and colleagues37 wished todetermine whether automated prompts could havemore general effects on clinically relevant behav-iors. They designed a brief within-subjects trial todetermine whether use of an electronic device, inthis case a voice organizer, could help 10 clientswith TBI recall the treatment goals they discussedwith therapists in case management sessions. In-dividualized therapy goals were randomly assigned

to an intervention consisting of recording andautomated playback on the organizer, or no inter-vention (which meant goals were emphasized inthe case management session, but not recorded).After 1 week, recorded goals were recalled signifi-cantly better than unrecorded goals. There wasalso some indication that participants in the trialwere more conscious of their recorded goals andmore likely to follow through with them. Buildingon the work of Hart and colleagues,37 Kirsch et al38

reported an intervention for an individual withmoderately severe TBI, whose primary behaviordifficulty was marked verbosity. An interventionwas designed using a PDA that delivered a mes-sage at fixed intervals, recorded in the participant’svoice, that instructed him to be brief. As antici-pated, the participant’s average utterance lengthduring 45-minute group sessions systematicallydecreased in response to cueing, although thenumber of utterances during the group did not.

Research that evaluates the efficacy of an ATmethod in the limited context of a trial is anecessary first step. However, demonstrating theeffectiveness of an intervention method, includingAT, requires evaluating the utility and impact ofthe method in the larger context of the user’s “reallife,” and over a more protracted period of time.Research that has taken this broader perspectivesuggests that a set of key factors in the usabilityand effectiveness of AT is the extent to which itmeets a user’s personal needs and expectations andprovides perceived value and benefit.39,40 More-over, although randomized controlled studies areimportant for establishing an evidence base forinterventions, results at the group level have notyet illuminated the process of determining indi-vidualized needs for AT support.7–9 Clinically,there is a need for new devices and other supportsthat are completely customizable with low cogni-tive, sensory and physical demands.9,41–44 Differ-ent populations with cognitive disability (eg, de-velopmental disability, TBI and stroke, and agingand dementia) may need very different kinds ofsupports due to differences in age, literacy, andfamiliarity with technology, as well as diversepsychological and psychosocial needs.12,40

These needs are beginning to be addressed asmore cognitive assistive technologies become avail-able. This increase in technology is driven in partby mainstream demand, because even people with



typical cognitive abilities seek supports for dealingwith increasingly complex scheduling and infor-mation-processing demands in the modern world.The increase in technology is also driven in partby an increased recognition of the needs of peoplewith all forms of cognitive disability.42

V. ADVANTAGES OF ELECTRONICATC DEVICES

Taken together, the studies cited previously suggestthat persons with cognitive and neurobehavioralchanges, including memory and organizationaldeficits, can compensate for some of these difficul-ties by using portable electronic devices. It is no-table that in many of these investigations, partici-pants were chosen for the severity of their cognitiveimpairments and had failed in the use of traditionalstrategies. Below we discuss several specific advan-tages that may be found to accrue from the use ofthe newer, “high-tech” ATC.

A. Possibility of Lasting Benefit

For some persons, improvement on prospectivememory tasks has been shown to persist after thedevices are withdrawn, suggesting that the devices’repeated cues can become internalized.32,33,35

B. Portability

Devices such as hand-held computers and pagersare conveniently sized and able to travel every-where with the user.

C. Consumer Acceptance

In one survey of people with acquired brain injuryregarding everyday memory aids and their effec-tiveness, electronic strategies were rated as moreeffective overall than paper strategies.45 However,only a small number of survey respondents in thatstudy had ever used electronic aids. Recently, Hartet al.25 surveyed 80 persons with moderate-to-severe TBI, most of whom were chronically dis-abled, regarding their interests and experiences

with portable reminding technologies. Both in-terest in and comfort with new technologies wererelatively high, suggesting general receptivity totechnological solutions. The majority of partici-pants said that they would like to use devices foreveryday memory and organizational tasks, butthis interest was not strongly related to perceivedneed for strategies, which was low overall. Thissuggests that persons with acquired brain injurymight not initiate use of assistive electronic de-vices after injury but may be receptive to usingthem, if they are offered within a clinical program.Thus, compared to paper-and-pencil memory andorganizational aids such as notebooks, portableelectronics may be more acceptable, even desir-able, to rehabilitation consumers.

D. Other Psychosocial Benefits

In addition to allowing users to accomplish tasksmore independently and freeing up caregivers’ time,authors have pointed to the potential for psycho-logical benefit from the use of portable electron-ics46–48 such as the social acceptability of beingreminded by a device rather than another person,which could be perceived as nagging. For reasons ofboth effectiveness and acceptability, mastering theuse of commercial technologies could serve to in-clude, rather than stigmatize or exclude, disabledpersons from the mainstream of society.36

VI. DISADVANTAGES AND REMAININGQUESTIONS ABOUT ELECTRONIC ATC

A. Efficacy Versus Effectiveness

As discussed above, efficacy studies do not necessar-ily speak to effectiveness in the real world. Thestudies to date have evaluated the efficacy of elec-tronic ATC in limited clinical or experimentalsituations. Effectiveness of ATC implies on-goingsuccess, about which there remain many questions.Will persons with cognitive disabilities be able totroubleshoot technical problems that may accom-pany long-term use of electronic devices, such asbattery failure? Will a caregiver be required toassume responsibility for on-going training and



support? A demonstration of clinical effectiveness(as well as cost-effectiveness) may depend on theindividual’s ability to use the device without thetechnical assistance and close monitoring of others.

However, even for individuals who requiresome assistance for physical tasks (eg, rechargingand replacing batteries) or maintenance tasks thatcannot be easily automated (eg, hot-syncing aPalm-type device), the overall functional benefitsto users and caregivers may far outweigh theserelatively minor inconveniences. Another unre-solved issue is that a clinically effective devicewould most likely be used for more than onepurpose as a memory/organizational aid, whereasmost of the research to date has focused on one,or a few, demonstrated activities.

B. Does Electronic ATC Work Better ThanMore Familiar Strategies?

Few studies to date have compared the efficacy ofelectronic ATC to other strategies more commonlyused for prospective memory. Even if high-techdevices are shown to work for prospective memorytasks, how do we know whether they work betterthan diligently applied, lower-tech strategies?

A few investigations have addressed this ques-tion. One study of persons with Alzheimer’s Dis-ease found that electronic alarms acted as highlyeffective reminders, whereas a traditional writtenschedule of activities was no more effective thansimply receiving verbal instructions to do things atspecific times.49 More research of this nature wouldhelp to establish which cognitive assistive deviceswork best compared to others, and for whom.Comparative interventions could also be struc-tured in a variety of ways to help determine the“active ingredients” of using an electronic aid: Arethe important variables the modality of output(eg, spoken vs. written), the automatic promptingfunction, the availability of interactive guidance,or some combination of these factors?

C. Can People with Cognitive DisabilitiesManage Their Own Technology?

Persons with disabilities are often on the wrongside of a “digital divide,” with less technology

access and expertise than nondisabled persons.50

Although cost is often cited as a barrier to procur-ing and using technology, cognitive as well asphysical impairments may also make it very chal-lenging to learn and use new technologies.51

Cognitive limitations may be more salient thanfinancial factors in affecting access to new tech-nologies. As mentioned above, the alarm functionon most devices may help remind users to initiateuse of AT, but this advantage presupposes thatsomeone has been able to figure out how to set thealarm. Commercial device interfaces may be dif-ficult or impossible for persons with disabilities touse, requiring expensive custom programming.52

Although research is needed to help determinewhat types and levels of ability are needed to learnand operate many types of assistive technology,and to evaluate how devices should be changed toaccommodate users with cognitive as well as physi-cal disabilities, high-tech ATC may present itsown set of challenges. Previous authors53 havespeculated about client characteristics that maypredict success with electronic devices among per-sons with brain injury, but these have not yet beentested systematically. A survey of clinicians work-ing in TBI rehabilitation54 revealed that learningand memory, fine motor skills /dexterity, motiva-tion, attention skills, and insight into deficits werebelieved to be the most important foundationskills for achieving success with electronic ATC. Itis somewhat paradoxical that respondents consid-ered learning and memory to be a prime targetarea for remediation with devices, yet learning andmemory were also considered necessary for suc-cessful use of high-tech ATC by nearly half thesample. Thus, when clinicians consider good can-didates for this type of AT, it appears that personswith some basic level of learning skill who, none-theless, need a compensatory memory strategy,and are aware of this need, are the best candidates.However, these are assumptions that need to beput to empirical test.

It is important to note that assistive technol-ogy devices and systems can be developed thataccommodate some of these user-based limita-tions. For example, if a person has difficulty settinga PDA alarm, interventions might need to includealarms, or even entire schedules, that are set re-motely and then transmitted to the user’s device atappropriate times. This was the model used in the



1990s to develop the NeuroPage system.31–33 Simi-lar interventions, using devices with a greaterrange of features, may include pictures, voicecommands, greater interaction between the userand the cueing system, including responses sent bythe user to the system in response to cues orqueries, and modifiability over time in response touser performance. For users whose cognitive char-acteristics serve as barriers to the successful opera-tion of an electronic device, automated, quasi-intelligent, or remotely managed devices may bemore beneficial than the off-the-shelf versions.For such individuals, “transparent” systems mayeven be helpful, in which behavior is monitored orcues and interventions presented in ways that donot appear to the person to be associated with atechnological system. For example, for personswho are unable (or unwilling) to operate even asimple technological device, environmental sen-sors that note when an activity component hasbeen performed (eg, opening the refrigerator) ora specific location has been entered (eg, the diningroom), may be far more beneficial than requiringthat a user generate a response. Similarly, systemsthat implicitly incorporate acquisition of a userresponse (eg, sensing that a piece of bread was putinto the toaster), rather than requiring an inde-pendent confirmation of this activity (eg, by touch-ing a device), may be most appropriate for personswho would be distracted if required to generate aresponse that is independent of the primary activ-ity being performed.

VII. THE IMPORTANCE OF ASSESSINGTHE MATCH OF INDIVIDUAL ANDDEVICE CHARACTERISTICS

Expanded choice in devices and features meansdifferences among individual users can be accom-modated. However, this also means that the pro-cess of matching person and technology can bemore complex.7,8 All aspects of a person’s cogni-tive, physical, and sensory capabilities must betaken into account in recommending technol-ogy.7,12,44 Features that are designed to address oneimpairment may negatively impact other aspectsof the person’s needs. A reminder system that isdesigned to be small and portable, so that a personwith a memory impairment can easily carry it

wherever he or she goes, may have such smallcontrols and displays that a person with fine motoror visual impairments cannot use it. Similarly, adevice that is highly customizable to a person’sneeds may be too complex for someone with acognitive disability to learn how to use, unless theuser interface is sufficiently simple.44

The complexity of matching a person andtechnology does not only arise from the individual’sunique combination of physical, sensory, and cog-nitive abilities. In addition, people’s expectationsof and reactions to technologies are complex andhighly individualized.7 These reactions emergefrom varying needs, abilities, preferences, and pastexperiences with and exposures to technologies.Predispositions to technology use also depend onone’s temperament/personality, subjective qualityof life/well-being, views of physical capabilities,expectations for future functioning, and financialand social /environmental support for technologyuse.7,55,56 These factors and considerations havebeen organized into a model of influences predis-posing individuals to varying degrees of techno-logy and other support use.7,9 The model has beenoperationalized by a series of assessment instru-ments56 addressing the match of individual anddevice characteristics and the relevant environ-ments most impacting a good match.

In the example of a high-tech ATC such as aportable electronic device, matching the indi-vidual and the device also means specifying thenature of the interface so that the user gets theright amount of support, yet is afforded the rightamount of flexibility, to accomplish the desiredtask(s) within his/her cognitive capabilities. Weexpand upon this theme below in a discussion ofprogramming high-tech devices as ATC.

VIII. CONSIDERATIONS FOR SELECTINGTYPE OF USER INTERACTION WITHELECTRONIC ATC

Three general approaches to electronic ATC in-tervention have been explored, each emphasizingdifferent types of user interactions with devices.

1. “Single message–static response” systems areoften based on devices such as pagers, tele-phones, or personal digital assistants. These



systems simplify interaction by restrictinguser responses to a single-button press (orfunctional equivalent such as a screen tap) inresponse to messages that provide cues abouttime-constrained tasks.31,33,37 In effect, thesedevices are like sophisticated alarm clocksthat can provide cues at preselected intervals.

2. “Personal organizational systems” provide anactive method for users to enter, manage,and use information such as daily appoint-ments, to-do lists, and financial records.Some of these systems (eg, PEAT,57

Autominder58) are based on personal digitalassistants but incorporate specialized soft-ware designed to facilitate use by individualswith cognitive disabilities. Other off-the-shelf systems offer software “suites” that in-clude calendars, word processing, and money-management programs. The degree to whichthe user can use these applications dependson the system, the task to which it is applied,and the ability of the user. For example, acommercial PDA may be usable and usefulfor a person with mild cognitive impair-ments, or for someone who is moderatelyimpaired who learns and uses only one of itsfunctions by rote. However, comprehensiveuse of many PDA functions can be challeng-ing, even for persons without cognitive dis-ability. On the other hand, PEAT57 orAutominder58 use software routines that canmanage fairly complex scheduling tasks thatare not available on standard PDAs. Fromthe user’s perspective, the responses requiredto use the device may be indistinguishablefrom a single message-static response systembecause the “reasoning” necessary to managedaily schedules is handled by the software.

3. “Interactive activity guidance” requires a re-sponse from the user that provides the systemwith information about the status of a task (ie,the user’s progress while performing the task)in order to make decisions about subsequentcues and alarms (Kirsch et al,41 MAPS,59

PocketCoach,60 Jogger61). The distinguish-ing characteristic of these interventions is thatthey present message sequences that correspondto the stages of an activity, requiring users ateach stage to provide input about task statusor error conditions.

Because interaction is such a critical compo-nent of these interventions, early decisions mustbe made during the discussion of device selectionabout the interface that will best suit the user’sneeds and preferences. Interface features must beconsidered regarding the device or system that willbe used, as well as the task that is to be performedusing the device or system. The degree to whichthese two interface issues are related varies accord-ing to the particular intervention. For some inter-ventions, a commercial device can be used withoutmodification. For example, a person having mildimpairments may require nothing more than astandard personal digital assistant to maintaindaily appointments. However, for persons havingmore severe impairments, device simplificationmay be necessary because the standard deviceinterface is too complex, too feature rich, or notsufficiently “intuitive.” Additionally, in these cases,learning over time through practice and rehearsalmay be required, even subsequent to modification.

Occasionally, device and task interface deci-sions are integrated, or at the very least, inform eachother, particularly for specialized, user-specific, in-terventions. For example, Hiroshi Ishii has main-tained a “Tangible Bits” research program at MITthat presents a unique approach to issues of ubiq-uitous, context-aware computing, and promotesthe conceptual integration of device and task. Insuch systems, the user engages the computing sys-tem by engaging in the task, without having toconsider, as a separate cognitive task, interactingwith the computational system’s interface. For ex-ample, Ishii and colleagues62 developed a system tofacilitate urban planning that presents the user withmodeling components (eg, model houses, officebuildings, roads). In performing the planning task(ie, moving and placing these tangible componentsto construct a model for an urban plan that incor-porates features such as changing shadows, buildingreflections, and wind patterns), the user transpar-ently engages the computational system withoutrequiring that any additional interface features bemanipulated. Other projects include toys that areable to learn movement after being manipulated(eg, blocks that, when constructed in the shape ofa dog, will learn to walk after they are manipulatedin a walking pattern)63 or an art set that allows achild to point to and touch objects in a room withan electronic “brush,” acquire the color of what was



touched, and then paint with that color on an easel-sized screen.64 Researchers at MIT have also pre-sented data showing that memory cues presentedthrough a wearable system in “real time” can besubliminal, in order not to divert the user’s atten-tion from the task at hand, and still enhanceperformance.65 Although these developments havegreat potential for clinical applications, this level ofintegration cannot yet be achieved in rehabilitationsettings. Typically, an intervention in a rehabilita-tion context will incorporate a device that is thenapplied to a task. The design of device interfacesand task interfaces are distinguishable operationsand are worth contrasting. However, the abovestudies are noted because the goal of an effectiveATC intervention may often be to develop a userinterface that is as transparent as possible. This willparticularly be the case for individuals having mod-erate to severe deficits, whose cognitive impair-ments limit the ability to interact effectively witha device.

A. Device Interface Design

Device interface design typically concerns itselfwith software and hardware features that are usedto interact with the device or system. For example,designers may consider a number of features, suchas the following:

• How many buttons can optimally be pre-sented by a device (eg, fewer buttons mini-mize configural complexity but may increaseprocedural complexity by requiring that thesame button be used for multiple purposes);

• whether the buttons are labeled with words(eg, “Min” and “Hour” buttons on an alarmclock or the “Talk” button on a cell phone) oricons (eg, application buttons on a PDA);

• whether alternative pathways are presented forachieving the same result (eg, being able topress a physical button on a PDA to launch thenote pad, as well as tapping an icon in a folder);

• how many button presses or mouse clicks arerequired to “drill down” through menus inorder to find needed features; and

• whether a specific interface feature can behidden or “docked” when not needed (eg, anunobtrusive toolbar).

Device design requires attention to both physicaland cognitive factors. For example, when develop-ing a thumb keyboard for a PDA or two-wayalphanumeric pager, designers may consider physi-cal variables such as key size, spacing, and tactileresponsiveness, based on information about modaluser finger size, strength and dexterity. However,designers may also consider cognitive factors inorder to improve efficient use of the keyboard.Along these lines, alternative virtual keyboardshave been proposed that improve performance(after practice) by rearranging letter placementbased on statistical analysis of letter digraph fre-quency (eg, in English, the digraph “t–h” occursmore frequently than “b–r” and both far morefrequently than “n–u”). For virtual keyboards,which are used with one-handed tapping, for someusers words per minute can be increased by arrang-ing letters so as to decrease average interlettersearch time and stylus excursion distance.66

As an example of iterative device interfacedesign, Kirsch, et al.38 reported the developmentof an ATC intervention for management of ver-bosity after moderately severe TBI, with othercomplicating factors including a long history ofalcohol abuse. The intervention that was eventu-ally tested in the reported study presented a cue tothe user, at 15-minute intervals, instructing himto “be brief.” The cue was recorded in the user’sown voice and presented by a Palm-type PDAthrough an earphone while the user was partici-pating in group therapy sessions. The results ofthis study indicated that utterance length wasreduced in response to intervention, as might beexpected given the cue to “be brief,” but utterancefrequency was not reduced, suggesting a high levelof response specificity. However, the interventionthat was reported represented the last of severalinterventions that were each briefly negotiatedand tried with this participant as part of an itera-tive design process. During earlier iterations, thecue was recorded in a therapist’s voice but changedto the user’s voice because he insisted he would beless likely to respond to a directive from anotherperson. Similarly, another earlier interventionpresented cues at a much briefer intercue interval,but the participant became frustrated with fre-quent interruptions, at one point angrily strikingthe touch screen of the PDA with a stylus. Length-ening the intercue interval eliminated this level of



frustration. Frustration and potential embarrass-ment was also minimized by concealing the devicein the participant’s pocket and having him tap thescreen with his finger, rather than with a stylus.

B. Task Interface Design

In contrast to device interface design, task inter-face design concerns itself with the activity forwhich an assistive device will be used. Since ATinterventions are prescribed to facilitate perfor-mance of functional tasks, these tasks must beanalyzed and assessed in much the same way thatthe device must be assessed. In our estimation, themost critical issues associated with task analysisand implementation are normative task difficultyand the user’s level of cognitive impairment. Thedegree to which these two interface issues arerelated varies depending on the intervention. Aperson with mild cognitive impairments subse-quent to traumatic brain injury (TBI) may requireno modification other than the use of a PDA tomanage information. However, for individualswhose cognitive functioning has been more sig-nificantly compromised, the task itself, includinghow a person interacts with the task, may have tobe modified. For example, tasks can be simplifiedby reducing the number of steps, limiting thenumber or types of items to be used or manipu-lated, or by requiring that a task be completedwithout interruption (ie, controlling branching toother tasks or multitasking).

In clinical practice, task interface requirementswill often be determined by the specific error pat-terns observed when the user performs a targetactivity. These errors are likely to represent aninteraction between the user’s cognitive profile,device features, and the cognitive demands of thetask to be performed. Some cognitive difficultiesare likely to be so pervasive that they will beexpressed across many tasks, often regardless ofcontent or difficulty. For example, a person withsevere memory problems may have difficulty withthe explicit acquisition of new information—animpairment that limits not only the performance offunctional tasks, but, as noted above, the acquisi-tion of the steps necessary to use a compensatorydevice. However, in many cases, the emerging errorpattern will be characterized by seemingly idiosyn-

cratic errors that are not evident when the personis performing other tasks. In either case, errorpatterns must be analyzed carefully in order todevelop hypotheses about intervention features thatpromote a compensatory approach to the task.

The process of task simplification can be quitechallenging. Users are subject to distraction, mis-understandings, interruptions, mood variation,fatigue, and many other factors that interfere withconsistent performance. Additionally, the envi-ronment or context in which a task is to beperformed may vary from day to day. Because ofthese variables, it will often be necessary to rede-sign an intervention, sometimes repeatedly, bychanging task interface features so that thesesources of variability are controlled and errorssystematically minimized. However, this idealcannot always be achieved. At some point in thedesign process, it may become evident that for anindividual with very high variability in error pat-terns across trials, the level of task interface restric-tions necessary to assure accurate performancemay be far more restrictive than what is reason-able, given the goal of achieving assisted indepen-dence for the task, and interventions other thanATC may be necessary.

As an example of iterative task interface de-sign, Kirsch et al41 presented the case of an elderlywoman with severe cognitive impairments (subse-quent to TBI against a backdrop of probableprogressive cognitive decline) who had difficultysetting her alarm clock. The study reports anintervention using pictures of the participant’salarm clock presented interactively on wirelessenabled laptop computer, with instructions abouthow to complete the task.

During clinical assessment, the severity of theparticipant’s cognitive impairments had been wellestablished. However, it would not have beenpossible to predict the specific and sometimessurprising errors she made when attempting tocomplete the task independently (ie, without ATguidance). In one instance, she had difficultycomprehending the text “Hour” and “Min” underassociated alarm clock buttons. A variety of cuemodifications were attempted to improve perfor-mance, but all were unsuccessful until the buttons,with associated visual cues, were color coded. Inanother instance, the participant perseverativelymaintained pressure on one of the clock buttons,



thereby scrolling the digital display beyond thecorrect alarm time. Several alternative cues werealso attempted to correct this error, but all wereunsuccessful until explicit directions to release thebutton were included in the cue set. To achievedevice and task interface presentations that sub-stantially reduced errors, multiple iterations of theATC intervention were required until the percep-tual elements of the clock and sequential elementsof the task had been changed enough so that errorincidence was reduced to acceptable levels.

In our experience, for many ATC interven-tions, iterative changes like these will be neces-sary. The first “pass” intervention, and perhaps thethird or fourth, may not adequately promote ac-ceptable target activity performance, either be-cause an error that occurred during an earlierdesign iteration was not successfully eliminated orbecause new errors emerge in response to inter-vention changes that had not previously occurred.For this reason, as will be noted in the “Rehabili-tation Team” section below, it is critical that anyATC intervention, even those using “off the shelf”devices or systems, be developed with a full under-standing of the user’s clinical status, includingstimuli and environmental circumstances that arelikely to either minimize or exacerbate behaviorsthat result in error.

Our clinical experience suggests that as symp-tom severity increases, direct modifications to thetask interface become increasingly important.These modifications are often preemptive, in thatthey guard the user against errors by offeringalternative ways of performing a task that take theuser’s cognitive characteristics into account. Sucha strategy not only improves performance but mayenhance learning over time, even for persons withsevere memory impairment, through errorlesslearning. This form of learning, contrasted with“trial-and-error,” appears to benefit those withsevere explicit memory deficits by capitalizing onthe residual implicit memory system.67.68

However, it should also be noted that everypotential user may not benefit from an ATC ap-proach (just as every rehabilitation therapy con-sumer will not benefit from any one single inter-vention). In particular, this will be the case for userswhose cognitive and behavioral presentation ischaracterized by unpredictable error variability acrosslearning sessions (attributable, say, to a specific

pattern of cognitive impairments or a particularlevel of impairment severity), or users for whom thebest comprehensive efforts to match them withappropriate technology is simply not successful.

IX. THE IMPORTANCE OF SKILLED ANDKNOWLEDGEABLE PROVIDERS

Another element of the environment that is key toan individual obtaining the most personally appro-priate device is the availability of trained and skilledAT providers who are knowledgeable about assess-ing consumer needs and preferences, devices, inter-face options, etc., and who are able to provide themost appropriate services. In addition to definingassistive technology devices, the Tech Act of 1988defined assistive technology service, as follows:

Any service that directly assists an individual with a disabilityin the selection, acquisition, or use of an assistive technologydevice, including...evaluation of the needs of an individual...;Purchasing, leasing, or otherwise providing for the acquisi-tion by an individual with a disability of an assistive technol-ogy device; Selecting, designing, fitting, customizing, adapt-ing, applying, maintaining, repairing, or replacing assistivetechnology devices; ...Training and technical assistance...

The communication problems and difficultywith memory, reasoning, and problem solvingexperienced by many people with cognitive dis-abilities requires skilled professionals trained tohelp consumers identify and understand theirstrengths as well as limitations, evaluate whetherself-perceptions of strengths and limitations arerealistic, and facilitate the expression of desiredgoals, preferences, and expected technology ben-efits. Clinician attitudes and expectations areimportant for selecting, training, and supportingthe use of any assistive technology—high- or low-tech—and may strongly affect the acceptance anduse of devices by clients.70 Clinician knowledge isone of the key factors that determines whetherconsumers are appropriately matched to assistivetechnology,69 and ongoing training and supportfrom professionals is considered vital to the successof compensatory devices.70

Clinicians involved in rehabilitation routinely,even casually, experiment with their clients usinglow-tech assistive devices, such as paper-and-pen-cil systems, for enhancing memory and organiza-



tion. However, clinical experimentation using high-tech strategies is much more infrequent and diffi-cult and carries higher stakes, partly resulting fromthe costs of emerging technology.70–72 Cliniciansmay also be reluctant to experiment with emergingtechnologies due to lack of knowledge or low con-fidence in their ability to keep up with rapid tech-nological changes. For example, in the cliniciansurvey cited above, about half of the respondentshad already been exposed to clients who used orattempted to use commercially available portableelectronic devices. However, relatively few expressedconfidence in their ability to train or support clientsin the use of such technology.54 Thus, many profes-sionals want to be, and realize they need to be, moreconsumer responsive but have not received thetraining they need in how to efficiently and effec-tively accomplish this.73–74

X. ATC AND THE REHABILITATION TEAM

The increasingly important role of ATC in therehabilitation of persons with cognitive impair-ment has been recognized by many in the field ofphysical medicine and rehabilitation. However,the challenge as to how to most successfully offer,provide and support the use of AT with rehabili-tation populations has not been met.

Considerations for the rehabilitation teamcan be encapsulated by the “5 w’s and h”:

• Why? Determining what the ATC needs todo for the user.

• Who? Multidisciplinary and coordinatedapproach.

• When? Repeated assessment of ATC needs.• Where? Home or community evaluation of

ATC use.• What? Incorporating training of ATC in

rehabilitation.• Follow-up and support for ATC.• How? Training rehabilitation professionals

on ATC

Why? Determining what the AT needs to do forthe user. No single person on the rehabilitationteam can be expected to know every availableresource and device that might be appropriate foruse as an AT persons with cognitive disability.

Specialized expertise usually exists in the facility orcommunity on the part of rehabilitation engi-neers, occupational therapists, neuropsychologists,and so on. But any member of the rehabilitationteam can and should listen to and observe thepotential user in order to understand that person’sstrengths, weaknesses, preferences, and goals.When these are discussed among the team mem-bers, a comprehensive picture of the need, fol-lowed by strategies and potential supports, can bebetter developed.

Who? Multidisciplinary and coordinated approach.Part of the challenge of the successful applicationof ATC for persons with cognitive impairmentsmay be securing the multidisciplinary approachthat appears to be an essential component forproviding ATC to patients and families. In fact,a review of the literature demonstrates that ATCresearch has been tackled by a variety of rehabili-tation professionals, including occupational thera-pists, physical therapists, rehabilitation engineers,physiatrists, and psychologists. Although theseprofessionals are typically not formally trained intechnological development or application, and assuch may not have the expertise to fully includeevery possible factor (such as usability and ergo-nomic adaptations), a multidisciplinary approachand good communication among the various teammembers is what is most important for providingthe necessary considerations for the successful in-tegration of ATC. An effective multidisciplinaryteam implementation of an ATC program should,thus, have individuals who represent such skills asclinical assessment and intervention, knowledgeof what is and isn’t available, knowledge of whatspecialized interventions are possible, knowledgeabout the devices, knowledge about assessment,and so on. In other words, the effective teamincludes a comprehensive skill set, perhaps aug-mented with consultation.

When? Assessment of ATC needs. In a recentstudy examining the use of assistive devices instroke survivors, researchers reported that initialneeds (at discharge) for assistive devices were pre-dominantly aids for mobility and physical assis-tance. However, at a 3- to 5-year follow-up, therewas a significant increase in the need for assistivedevices for cooking/eating and reading/hearing/writing.75 These findings may suggest that theinitial evaluation of ATC needs may be focused on



physical needs, but the cognitive needs, whichtypically impact activities of daily living, may notbe identified early on. This point may be particu-larly salient for individuals with cognitive impair-ment who also have physical impairments, such asstroke or multiple sclerosis.

Similarly, there has been some evidence thatindicates that the highest prescription for AToccurs early in the acute rehabilitation phase.76 IfATC is not considered early enough, and cogni-tive issues are addressed in the acute phase, indi-viduals may not receive the appropriate supports.On the other hand, some cognitive impairmentsmay become apparent only postacute rehabilita-tion or upon the return to home. This indicatesthe value of an additional or secondary evaluationof ATC needs by a rehabilitation specialist postacute rehabilitation, as well as an evaluation earlyin rehabilitation.

Where? Home or community evaluation of ATCuse. Given the diversity of environments whereATC devices may be used, consideration of wheretraining and evaluation is conducted should beaddressed by the rehabilitation team. Although amajority of evaluations are conducted in the clinicor hospital, home evaluations may offer a uniqueopportunity for evaluating the interface betweenthe user and the ATC device in a more naturalsetting and provide a chance to address unforeseenproblems. Similarly, vocational rehabilitationprofessionals, working in conjunction with therehabilitation team, may also take advantage ofon-the-job training to evaluate the use and inte-gration of the ATC device in work settings. Thegeneralization of ATC use to functional commu-nity settings is critical, but assessment in the clinicis necessary as a first step to see if the ATCintervention is even reasonable and a good matchwith the user. Early prescription provides the basisfor making initial decisions, whereas ongoing re-evaluation, modification, and incorporation intohome/community settings promotes generaliza-tion and sustained use.

What? Incorporating training of ATC in rehabili-tation and follow-up and support for ATC. As previ-ously discussed, an essential component of a com-prehensive evaluation includes the individual’sphysical, psychological/emotional, behavioral, andcognitive skills; an analysis of the features anddemands of the technology on the user; and the

physical and psychosocial aspects of the environ-ment most apt to influence the device’s use. It isthen essential that the user receive training in howto optimally use the device, as well as any main-tenance requirements (eg, recharging batteries).Once the individual receives training, then on-going support for use, upgrades in device features,and accommodations to the user’s changing capa-bilities will need to be made.

However, even issues of training may be influ-enced by a variety of factors. For some individuals,one-time training in the use of an electronic deviceor system may be all that is necessary. This may bethe case because their cognitive changes are mild orbecause the device interface is truly intuitive. How-ever, for users having far more severe cognitivechanges, assistive technology may still be useful, butuse may need to be transparent to the user. Forthose with very severe cognitive involvement, theymay benefit primarily from an ATC system’s inter-action with the environment (eg, turning off thestove automatically if it’s been left on to long;placing a call to a caretaker if difficulties arise)without the user even being aware that these inter-ventions have occurred. In our opinion, the criticalissue regarding the identification and prescriptionof ATC is that the multidisciplinary team be fullyapprised of available systems, how these systemsoperate, the range of applications to which thesystem features can be applied, and the user’s clini-cal status, so that the prescribed system matches theuser’s training (and other) capabilities. Having notedthis, it may be the case that caregivers, rather thanthe target user, may be the focus of training. Thisis also a critical responsibility of the team, particu-larly if the ATC system will be used in a home orresidential treatment context, without the benefitof daily intervention from the members of theprescribing team

How? Training rehabilitation professionals. Onemethod of training rehabilitation professionals onproviding AT services is the use of online orInternet-based education. Although many of thesehave not specifically focused on ATC, many of thebenefits offered through this training are appli-cable, such as (1) providing education on key issuesassociated with ATC (usability, technology-usermatching and ergonomics, and so on); (2) increas-ing awareness about the various types of ATC thatmay be available for the different types of impair-



ments; and (3) providing access to resources andexpertise. Recent studies examining the efficacy ofthis approach for general AT have served todemonstrate its usefulness in training practicingrehabilitation professionals.77

Individual characteristics of the therapist andof the therapist/patient relationship have beenexamined as they relate to the use of AT. Thereis some evidence that the greater the degree ofinvolvement by the therapist, the more likely theAT will be used and the more optimal its useful-ness.78 This may be a factor of “getting to knowthe patient and his or her needs” and, subse-quently, being able to identify the appropriate ATmatches for the individual. Greater therapist in-volvement may also specify the type of involve-ment the therapist should have with the individualand help identify and recommend additional ser-vices that may be needed to ensure the successfuluse of the AT by the individual. Finally, thebenefit of a multiple therapist and multidisciplinaryapproach can also be considered here. For ex-ample, although psychologists may have a goodunderstanding of an individual’s cognitive impair-ments, they may not have the opportunity to beinvolved with the individual during more func-tional everyday activities, as do occupational thera-pists. As such, an individual recommendation fromone therapist may not cover all of the key elementsfor matching the person with the ATC device.However, a combined evaluation and recommen-dation from both the psychologist and occupa-tional therapist may be a better solution for iden-tifying the individual’s ATC needs.

XI. ASSESSING OUTCOMES OF THEAT INTERVENTION

Although there are many devices appropriate foruse by persons with cognitive disabilities, todayabout 90% of AT for cognitive compensation isdiscarded after only brief use.73 Psychosocial fac-tors appear to underlie many instances of devicenonuse, partial, and inappropriate use. For exam-ple, users who do not believe that they are involvedin the selection of their assistive technology de-vices are more likely to discontinue using themthan individuals who feel involved.7 It has beenargued that people may discontinue using devices

because their personal expectations of performance,or the expectations of their caregivers, followingdisability onset may be reduced dramatically.7

This leaves open the matter of psychosocial factorsnot being adequately assessed, explored, and at-tended to before devices, which are often complexand expensive, are delivered.

The AT literature includes some good non-experimental (survey) research on what forms ofAT are discontinued and how often, but it has notaddressed persons with TBI. It is not clear, forexample, whether users in some instances havestopped using a device because of changes in theirlife circumstances that have nothing to do withhow well the device is designed, how well itperforms, or how satisfied the user is with itsperformance and usefulness. Other possible fac-tors associated with nonuse include unrealisticexpectations, inappropriate needs assessment, poordevice selection, lack of support from caregivers,and any combination of these.74

It is likely that a major overarching reason fordiscarding AT is that a device is not typicallyevaluated in the context of the whole person andhis or her environment, despite the fact that thisis in keeping with the World Health Organization’sInternational Classification of Functioning, Dis-ability and Health. Factors influencing sustaineduse that should be evaluated in the context of thatuse include the following: (1) The appropriatenessof specific device features (eg, is there a keyboard?;how big are the keys?; is the screen readily visible?;are there too many buttons?); (2) changing charac-teristics of the patient (eg, progressive memorydecline; decreased motivation associated with de-pression); (3) changing patterns of functionaldemands over time, such as changing demands athome or at work (which may render technologiesobsolete that were prescribed at an earlier time);and (4) psychosocial/interpersonal variables, suchas the degree to which a person receives support forAT use from others or the degree to which aparticular device is viewed by the person as stigma-tizing.7 Since AT interventions can be relativelyexpensive, further research on the factors thatcontribute either to nonuse or poor generalizationacross functional settings will be very important.

For many rehabilitation interventions, thefirst assessment “pass” must consider the immedi-ate impact of the intervention within a clinical



setting (ie, “does this intervention actually pro-mote a change in that behavior?”). This first “pass”determines whether it will even make sense for aclinical team to pursue further development of aspecific intervention, including whether effortsshould be made to incorporate the intervention inthe broader contexts of a user’s life. However, onceeffectiveness in the clinic has been established, asecond, and perhaps far more critical, “pass” re-quires appreciation of the many complex factorsthat are likely to affect sustained use of an inter-vention or the generalizability of the interventionacross functional contexts.

Regarding the first level of assessment, avariety of approaches can be adopted. Most typi-cally, AT interventions will be considered forspecific individuals facing specific problems. There-fore, single case methodologies will often be re-quired to assess the impact of an AT intervention.Many examples of this approach to assessmenthave been previously reviewed. These studies, as agroup, suggest that AT interventions can be usedeffectively to facilitate performance of functionaltasks that would otherwise require the AT user torely on supervision or guidance from anotherperson. However, as with all single-case designs,even those using multiple baselines across personsor tasks, generalizability will be restricted by thespecific constraints of the study, including thetarget behavior, modifications to the design inter-face required by the unique pattern of errors en-countered by the user during task completion, andthe nature of the supporting context in which theassessment study was conducted (eg, familiar vs.unfamiliar, relatively controlled clinical setting vs.relatively uncontrolled community setting, a singlebehavior repeatedly performed in a single settingvs. a single behavior that is performed acrossmultiple settings—all of which require a behaviorof that sort).

These types of assessments will often be re-quired, even if interventions are being consideredthat are based on a device developed for use bymultiple people (ie, a commercial product). Forexample, it has by now been well established thatalphanumeric paging systems can provide func-tionally significant support for persons with cog-nitive impairments by providing cueing aboutprospective tasks.21,31–33,48 However, even for suchdevices, individualized assessment will often be

important to establish various factors influencingclinical outcome for a specific user, such as

• mood, motivation for technology use, supportfor use, self esteem56;

• device ease of use, range of tasks for which thedevice is effective, response consistency overtime, whether different cue characteristics areneeded by different users at different times orduring different activities; and

• contextual barriers, such as environmentalnoise, and the degree of support from othersfor use.7

XII. CONCLUSIONS

This article has reviewed some recent work on theuse of ATC in rehabilitation programs, somecentral issues of importance in the design of suchinterventions, and the importance of a multi-disciplinary approach to ATC design and assess-ment. In summary, there are a number of criticalissues that are important to emphasize.

First, assistive technologies for cognition, likethe broader class of assistive technologies to whichthey belong, are most effective when they areshaped to meet and enhance a consumer’s particu-lar functional, personal, and social needs, notwhen they are prescribed as an isolated means ofaddressing a specific cognitive limitation. Tech-nologies that do not fit with consumer preferencesor preferred/customary ways of doing things havea decreased probability of use. Similarly, in ourexperience, technologies that address a compo-nent skill but do not demonstrate to users andcaregivers that functional improvement will beforthcoming, are also likely to be abandoned. Thequestion today is no longer whether or not toincorporate technology into rehabilitation, butwhich devices and product features will best ad-dress the functional needs and preferences of aparticular individual with a cognitive disability.Second, it is crucial that the process of matchingthe most appropriate ATC to individuals withcognitive disabilities involves a rehabilitation team.There are a number of reasons why we stress thispoint. The most critical is that ATC interven-tions, in our experience, are most successful whenthey are part of a comprehensive evaluation and



treatment plan. The diverse areas of clinicalexpertise represented on the treatment team areall necessary in order to identify an appropriateproblem area, experiment with nontechnologicalinterventions that can then be implemented withATC, and develop a method for assessing out-come within the context of a functional activity.Clearly, both clinical and technological skills arenecessary to develop devices and systems that willwork for cognitive disability.

Third, it is also critical that the process ofATC development and intervention not end inthe clinic or after a few weeks, but continues overtime and in the real world. Success with ATC willlikely depend upon on-going, repetitive trainingin the use of the device, modifications based onformal assessment, and the availability of up-grades as the user gains proficiency and makesprogress in rehabilitation. In the world of webdesign, this is known as iterative design. Webelieve strongly that this iterative approach iscritical to successful intervention design and alsofits well into a framework of systematic single-casestudies for the individualized evaluation of treat-ment efficacy.79

Fourth, when enabling a person to performdesired tasks, it is possible that assistive technolo-gies may provide a sense of competence andreconnection to the community. By accommodat-ing a person’s weaknesses and supporting his or herstrengths, assistive technologies can reduce psy-chosocial stressors, thus leading to renewed confi-dence and self-esteem. We believe that this is acritical area of continuing research, since it may bethe case that the renewed confidence associatedwith ATC use will, for some users, result inimproved functioning in other domains for whichATC was not even considered.

Fifth, as individuals with cognitive changesmake the transition back to community life, it iscertain that they will encounter difficulties thatare associated with how cognitive information ispresented in the environment. The approachesto ATC interventions that we have reviewed inthis article typically address the needs of anindividual who is having difficulty with sometype of task or behavior and is expected to benefitfrom external organization or cueing. However,these interventions cannot facilitate improvedfunctioning if the person’s cognitive environ-

ment is confusing or unintentionally husbandscritical information. Just as consumers and reha-bilitation professionals advocate for physicalaccessibility in the community, it is important toadvocate for cognitive accessibility. Much of theinformation derived from ATC studies may havea direct bearing on recommendations for cog-nitively accessible community design, includinghow information is presented (eg, signage, menus,voice mail messaging systems with multiple menulevels, application forms) or even whether infor-mation is made available more readily and acces-sibly (eg, information kiosks). In some respects,the community itself can be construed as a “userinterface.” We believe that information derivedfrom studies investigating ATC design and imple-mentation will be critical to the design of com-munities that facilitate the full inclusion of indi-viduals with nonmodal cognitive abilities.

As the individual cognitively improves or de-teriorates, there will also be a need to revisitconsumer goals and device appropriateness. Forthese and many other reasons, outcome assess-ment is a critical component of AT developmentand selection. Thus, the consideration of ATinvolves a cycle of consideration from appropriatedevice evaluation and selection, use in naturalenvironments, upgrading and accommodatingusers’ changing needs and preferences, and theprovision of follow-up and follow-along supportfor use.

ACKNOWLEDGMENTS

The authors come from different rehabilitationcenters and varied areas of expertise, but theyshare an active involvement in the AssistiveTechnology Task Force of the Brain Injury Inter-disciplinary Special Interest Group, which is af-filiated with the American Congress of Rehabili-tation Medicine (ACRM). We acknowledge withgratitude the opportunity ACRM has afforded usto collaborate on approaches to improved provi-sion of AT to individuals with cognitive disabili-ties. We also acknowledge with gratitude thesupport of our colleagues affiliated with the Reha-bilitation Engineering Research Center for theAdvancement of Cognitive Technologies, Uni-versity of Colorado.



REFERENCES

1. World Health Organization. The World Health Re-port 2001: Mental Health: New Understanding, NewHope, Mental and Neurological Disorders. 2001.Retrieved April 20, 2004. Available from: http://www.who.int/whr2001/2001/main/en/media/disorders.htm

2. Brain Injury Association. 2004. Retrieved April 20,2005. Available from: http://www.biausa.org/Pages/what_is_brain_injury.html

3. Mateer C, Sohlberg M, Crinean J. Focus on clinicalresearch: perceptions of memory function in individu-als with closed-head injury. J Head Trauma Rehabil.1987;2(3):74–84.

4. Kinsella G, Murtagh D, Landry A. Everyday memoryfollowing traumatic brain injury. Brain Injury.1996;10:499–507.

5. Wehman P, Revell W, Kregel J, Kreutzer J, CallahanM, Banks P. Supported employment: alternative modelfor vocational rehabilitation of persons with severeneurologic, psychiatric, or physical disability. ArchPhys Med Rehabil. 1991;72:101–5.

6. Knight R, Devereux R, Godfrey H. Caring for afamily member with a traumatic brain injury. BrainInjury. 1998;12(6):467–81.

7. Scherer MJ. Living in the state of stuck: how technol-ogy impacts the lives of people with disabilities. 4thed. Cambridge (MA): Brookline Books; 2005.

8. Scherer MJ, editor. Assistive technology: matchingdevice and consumer for successful rehabilitation.Washington (DC): American Psychological Associa-tion; 2002.

9. Scherer MJ. Connecting to learn: educational andassistive technology for people with disabilities.Washington (DC): American Psychological Associa-tion; 2004.

10. Cicerone K, Dahlberg C, Kalmar K, Langenbahn D,Malec J, Bergquist T, Felicetti T, Giacino J, Harley J,Harrington D, Herzog J, Kneipp S, Laatsch L, MorseP. Evidence-based cognitive rehabilitation: recommen-dations for clinical practice. Arch Phys Med Rehabil.2000;81:1596–1615.

11. Cicerone KD, Mott T, Azulay J, Friel JC. Commu-nity integration and satisfaction with functioning afterintensive cognitive rehabilitation for traumatic braininjury. Arch Phys Med Rehabil. 2004;85(6):943–50.

12. Scherer MJ. Technologies and other supports for think-ing, remembering and learning. Invited presentation—Neural Perspectives: A Focus on Recovery Neuroscienceand NeuroRehabilitation Conference, INTEGRIS JimThorpe Rehabilitation Network, Oklahoma City. Sep-tember 20, 2003. Available on audiotape from https://www.integris-health.com/INTEGRIS/Locations/okc/JimThorpe/Community/Education/Continuing+Education+Series/neuraltapes.htm

13. Harris J. External memory aids. In: Gruneberg M,Morris P, Sykes R, editors. Practical aspects of memory.London: Academic Press; 1978.

14. Jones M, Adams J. Toward a prosthetic memory. BullBr Psychol Soc. 1979;3:165–7.

15. Wade TK, Troy JC. Mobile phones as a new memoryaid: A preliminary investigation using case studies.Brain Injury. 2001;15(4):305–20.

16. World Health Organization International Classifica-tion of Functioning, Disability and Health. Retrieved20 July 2005. Available from: http://www3.who.int/icf/icftemplate.cfm?myurl=homepage.html&mytitle=Home%20Page

17. Donaghy S, Williams W. A new protocol for trainingseverely impaired patients in the usage of memoryjournals. Brain Injury. 1998;12(12):1061–76.

18. Schmitter-Edgecombe M, Fahy J, Whelan J, Long C.Memory remediation after severe closed head injury:notebook training versus supportive therapy. J Con-sulting Clin Psychol. 1995;63(3):484–9.

19. Sohlberg MM, Mateer CA. Training use of compensa-tory memory books: a three stage behavioral approach.J Clin Exp Neuropsychol. 1989;11(6):871–91.

20. Ownsworth TL, McFarland K. Memory remediationin long-term acquired brain injury: two approaches indiary training. Brain Injury. 1999;13(8):605–26.

21. Wilson B. Cognitive rehabilitation: how it is and howit might be. J Int Neuropsychol Soc. 1997;3:487–96.

22. Prigatano G, Leathem J. Memory performance andthe use of compensation after traumatic brain injury.Neuropsychol Rehabil. 1993;3:53–62.

23 Kirsch NL, Shenton M, Rowan J. A generic, “in-house,” alphanumeric paging system for prospectiveactivity impairments after traumatic brain injury. BrainInjury. 2004;18(7):725–34.

24. Tate R. Beyond one-bun, two-shoe: recent advancesin the psychological rehabilitation of memory disor-ders after acquired brain injury. Brain Injury. 1997;11(12):907–18.

25. Hart T, Buchhofer R, Vaccaro M. Portable electronicdevices as memory and organizational aids after trau-matic brain injury: A consumer survey study. J HeadTrauma Rehabil. 2004;19:351-65.

26. Glisky E, Schacter D, Tulving E. Computer learningby memory-impaired patients: acquisition and reten-tion of complex knowledge. Neuropsychologia. 1986;24:313–28.

27. Glisky E, Schacter D, Tulving E. Learning and reten-tion of computer related vocabulary in memory-impaired patients: method of vanishing cues. J ClinExp Neuropsychol. 1986;8:292–312.

28. Glisky E. Acquisition and transfer of word processingskill by an amnesic patient. Neuropsychol Rehabil.1995;5(4):299–318.

29. Kirsch N, Levine S, Fallon-Krueger M, Jaros L. Themicrocomputer as an “orthotic” device for patientswith cognitive deficits. J Head Trauma Rehabil. 1987;2(4):77–86.

30. Kirsch N, Levine S, Lajiness-O’Neil R, Schnyder M.Computer-assisted interactive task guidance: facilitat-ing the performance of a simulated vocational task.J Head Trauma Rehabil. 1992;7:13–25.



31. Hersh N, Treadgold L. NeuroPage: the rehabilitationof memory of dysfunction by prosthetic memory andcueing. NeuroRehabilitation. 1994;4:187–97.

32. Wilson B, Evans J, Emslie H, Malinek V. Evaluationof NeuroPage: a new memory aid. J Neurol NeurosurgPsychiatry. 1997;63(1):113–15.

33. Wilson B, Emslie H, Quirk K, Evans J. Reducingeveryday memory and planning problems by means ofa paging system: a randomised control crossover study.J Neurol Neurosurg Psychiatry. 2001;70(4):477–82.

34. Van Den Broek M, Downes J, Johnson Z, Dayus B,Hilton N. Evaluation of an electronic memory aid inthe neuropsychological rehabilitation of prospectivememory deficits. Brain Injury. 2000;14(5):455–62.

35. Yasuda K, Misu T, Beckman B, Watanabe O, OzawaY, Nakamura T. Use of an IC recorder as a voiceoutput memory aid for patients with prospectivememory impairment. Neuropsychol Rehabil. 2002;12(2):155–66.

36. Davies D, Stock S, Wehmeyer M. Enhancing inde-pendent time-management skills of individuals withmental retardation using a palmtop personal com-puter. Mental Retardation. 2002;40:358–65.

37. Hart T, Hawkey K, Whyte J. Use of a portable voiceorganizer to remember therapy goals in TBI rehabili-tation: a within-subjects trial. J Head Trauma Rehabil.2002;17(6):556–70.

38. Kirsch NL, Shenton M, Spirl E, Simpson R, LoPrestiE, Schreckenghost D. Modifying verbose speech aftertraumatic brain injury with an assistive technology sys-tem for coordinated behavior-change cueing and moni-toring. J Head Trauma Rehabil. 2004;19(5):366-77.

39. Kilgore KL, Scherer M, Bobblitt R, Dettloff J,Dombrowski DM, Godbold N, Jatich JW, Morris R,Penko JS, Schremp ES, Cash LA. Neuroprosthesisconsumers’ forum: consumer priorities for researchdirections. J Rehabil Res Dev. 2001;38(6):655–60.

40. Scherer MJ, Lane JP. Assessing consumer profiles of“ideal” assistive technologies in ten categories: an inte-gration of quantitative and qualitative methods. DisabilRehabil. 1997;19(12):528–35.

41. Kirsch NL, Shenton M, Spirl E, Rowan J, SimpsonR, Schreckenghost D, LoPresti E. Web-based assistivetechnology interventions for cognitive impairments aftertraumatic brain injury: a selective review and two casesstudies. Rehabil Psychol. 2004;49(3):200-12.

42. LoPresti EF, Mihailidis A, Kirsch N. Technology forcognitive rehabilitation and compensation: state of theart. Neuropsychol Rehabil. 2004;14(1/2):5–39.

43. LoPresti EF, Friedman MB, Hages D. Electronicvocational aid for people with cognitive disabilities.Proceedings of the RESNA 1997 Annual Conference;Arlington, VA: RESNA Press; 1997. p. 514-6.

44. LoPresti E, Willkomm T. (1997). Comparison of com-mercially available electronic prospective memory aids.Proceedings of the RESNA 1997 Annual Conference;Arlington, VA: RESNA Press; 1997. p. 523-5.

45. Evans J, Wilson B, Needham P, Brentnall S. Whomakes good use of memory aids? Results of a survey of

people with acquired brain injury. J Int NeuropsycholSoc. 2003;9:925–35.

46. Kim H, Burke D, Dowds M, Goerge J. Utility of amicrocomputer as an external memory aid for a memory-impaired head injury patient during in-patient reha-bilitation. Brain Injury. 1999;13(2):147–50.

47. Wright P, Rogers N, Hall C, Wilson B, Evans J,Emslie H. Enhancing an appointment diary on apocket computer for use by people after brain injury.Int J Rehabil Res. 2001;24:299–308.

48. Wilson B, Scott H, Evans J, Emslie H. Preliminaryreport of a NeuroPage service within a health caresystem. NeuroRehabilitation. 2003;18:3–8.

49. Oriani M, Moniz-Cook E, Binetti G, Zanieri G,Frisoni GB, Geroldi C, et al. An electronic memoryaid to support prospective memory in patients in theearly stages of Alzheimer’s disease: a pilot study. AgingMental Health. 2003;7:22–7.

50. Wilson BA, Baddeley AD, Cockburn JM. How doold dogs learn new tricks: teaching a technological skillto brain injured people. Cortex. 1989;25:115–9.

51. Wright P, Rogers N, Hall C, Wilson B, Evans J,Emslie H, et al. Comparison of pocket-computermemory aids for people with brain injury. Brain Injury.2001;15(9):787–800.

52. Gitlin LN, Mount J, Lucas W, Wirich LC, Gramberg.L. The physical costs and the psychosocial benefits oftravel aids for persons who are visually impaired orblind. J Visual Impairment Blindness. 1997;91(4):347-59.

53. Giles G, Shore M. The effectiveness of an electronicmemory aid for a memory-impaired adult of normalintellegence. Am J Occup Ther. 1989;43(6):409–11.

54. Hart T, O’Neil-Pirozzi T, Morita C. Clinician ex-pectations for portable electronic devices as cognitive-behavioural orthoses in traumatic brain injury reha-bilitation. Brain Injury. 2003;17:401–11.

55. American Medical Association. Primary care for per-sons with disabilities: access to assistive technology:guidelines for the use of assistive technology: evalua-tion, referral, prescription. Chicago: American Medi-cal Association; 1996. p. 23.

56. Scherer MJ. Matching person & technology processand accompanying assessment instruments. Reviseded. Webster (NY): Institute for Matching Person &Technology; 1998. Available from: http://members.aol.com/IMPT97/MPT.html

57. Levinson R. PEAT: The planning and execution as-sistant and training system. J Head Trauma Rehabil.1997;12(2):85–91.

58. Pollack ME, Brown L, Colbry D, McCarthy CE,Orosz C, Peintner B, Ramakrishnan S, TsamardinosI. Autominder: an intelligent cognitive orthotic sys-tem for people with memory impairment. Robot Au-tonomous Syst. 2003;44(3–4):273–82.

59. Carmien S. MAPS: dynamic scaffolding for in-dependence for persons with cognitive impairments.Lecture Notes in Computer Science. 2003;2702:408–10.



60. AbleLink Technologies. Pocket Coach. RetrievedAugust 11, 2004. Available from http://www.ablelinktech.com/_handhelds/productview.asp?ID=18

61. Independent Concepts, Inc. The Jogger System. Re-trieved August 11, 2004. Available from: http://www.thejogger.com/

62. Ben-Joseph E, Ishii H, Underkoffler J, Piper B, YeungL. Urban simulation and the luminous planning table:bridging the gap between the digital and the tangible.J Planning Educ Res. 2001;21:195–202.

63. Solos-Raffle H, Parkes AJ, Ishii H. Topobo: a con-structive assembly system with kinetic memory. Pro-ceedings of the SIGCHI Conference on Human Fac-tors in Computing Systems; Vienna, Austria: Associa-tion for Computing Machinery; 2004. p. 647–54.

64. Ryokai K, Marti S, Ishii H. I/O brush: drawing witheveryday objects as ink. Proceedings of the SIGCHIConference on Human Factors in Computing Sys-tems; Vienna, Austria: Association for ComputingMachinery; 2004. p. 303-10.

65. DeVaul RW, Pentland A, Corey VR. The memoryglasses: subliminal vs. overt memory support withimperfect information. Proceedings of the 7th IEEEInternational Symposium on Wearable Computers;White Plains, NY: IEEE; 2003. p. 146.

66. Zhai S, Hunter M, Smith BA. Performance optimi-zation of virtual keyboards. Human-Computer Inter-action. 2002;17(2&3):229–69.

67. Wilson BA, Evans JJ. Error-free learning in the reha-bilitation of people with memory impairments. J HeadTrauma Rehabil. 1996;11:54–64.

68. Wilson BA, Baddeley A, Evans J, Shiel A. Errorlesslearning in the rehabilitation of memory impairedpeople. Neuropsychological Rehabil. 1994;4:307–26.

69. Scherer M. The impact of assistive technology on thelives of people with disabilities. In: Gray DB, QuatranoLA, Lieberman ML, editors. Designing and usingassistive technology: the human perspective. Baltimore(MD): Paul H. Brookes; 1998. p. 99–115.

70. Scherer M. The change in emphasis from people toperson: introduction to the special issue on assistivetechnology. Disabil Rehabil. 2002;24(1/2/3):1–4.

71. Fuhrer M. Assistive technology outcomes research:challenges met and yet unmet. J Am Phys Med Rehabil.2001;80:528–35.

72. Loebl D. A decision-making model for the provisionof adaptive technology. Am J Occup Ther. 1999;53:387–91.

73. Wachtel C. Development and delivery of a courseon “Technological Approaches to Cognitive Disa-bilities.” Poster presentation for Research Frontiersin Cognitive Disability and Technology (II), 2002Sept 26–27; Boulder, CO: The Coleman Institute;2002.

74. Cushman LA, Scherer M. Measuring the relationshipof assistive technology use, functional status over time,and consumer-therapist perceptions of assistive tech-nology. Assistive Technol. 1996;8(2): 103–9.

75. Sorensen HV, Lendal S, Schultz-Larsen K, UhrskovT. Stroke rehabilitation: assistive technology devicesand environmental modifications following primaryrehabilitation in hospital—a therapeutic perspective.Assist Technol. 2003;15(1):39–48.

76. Gosman-Hedstron G, Claesson L, Blomstrand C,Fagerberg B, Lundgren-Lindquist B. Use and Cost ofassistive technology the first year after stroke. A ran-domized controlled trial. Int J Technol Assess HealthCare. 2002;18(3):520–7.

77. Sax CL. Assistive technology education: an onlinemodel for rehabilitation professionals. Disabil Rehabil.2002;24(1/2/3):144–51.

78. Carmeli E, Chana C, Merrick J. The assimilation ofassistive technology in residential care centers for peoplewith intellectual disabilities. Sci World J. 2004;12(4):178–85.

79. Prigatano GP. Challenging dogma in neuropsychol-ogy and related disciplines. Arch Clin Neuropsychol.2003;18(8):811–25.


assistive technologies for cognitive disabilitiessg94g745/pubs/critrevin pmr... · i. assistive...

Documents