High Technology
for Handicapped
Children:
A
Pediatrician’s
Viewpoint
Larry
W.
Desch,
MD
From the Division of Developmental Disabilities, Department of Pediatrics, University of Iowa Hospitals, Iowa City
ABSTRACT.
Children with various types of disabilities are beginning to benefit from the extensive developments in the field of electronic and microcomputer technologythat have occurred in recent years. There exists now
many devices that can assist children with physical or
communication handicaps, learning difficulties, or
sen-sory impairments. Reviews of the literature were made
in order to present some of the devices that are currently
available and to introduce the concepts that they
exem-plify. With all of these devices, but especially for those
designed to aid physically or communicatively
handi-capped children, careful planning and evaluation is needed. Steps in the processes of evaluation and selection
of devices are outlined and discussed. Proper training and monitoring the use of these devices are other aspects that are addressed. Several issues dealing with the fund-ing of these devices and how these devices can be used in
innovative research, are also presented. Pediatrics
1986;77:71-87; high technology, handicap, assistive device,
disability.
The recent explosion in the popularity of
elec-tronic devices, specifically microcomputers, has
brought with it both insights and confusion about
computer and electronic technology. One day we
read that this technology is a threat; the next, we
read that it will greatly improve most aspects of our
lives. One thing is certain: it is this new technology
that is primarily responsible for the tremendous
advancement in new devices and opportunities for
children and adults with disabilities.
The use of this technology to assist people with
disabilities is currently undergoing nearly
exponen-tial growth, and it is impossible to be completely
aware of all that is available. This article, therefore,
Received for publication Sept 10, 1984; accepted April 29, 1985.
Reprint requests to (L.W.D.) Division of Developmental
Dim-bilities, Department of Child Health, University of Missouri
Hospital, Columbia, MO 65212.
PEDIATRICS (ISSN 0031 4005). Copyright © 1986 by the
American Academy of Pediatrics.
does not attempt to be comprehensive. Its main
intent is to give an overview of this area in a format
designed for physicians and other professionals who
provide care for children with disabilities. Instead
of expanding on particular devices, it presents basic
information concerning the selection, evaluation,
funding, and training in the use of these electronic
devices. Outlining these fundamentals will supply
these professionals with some concept that should
allow them to be better able to offer their assistance and expertise.
One way to measure the worth of a society is to
examine its ability and willingness to accommodate
the needs of children, the elderly, and those that
are disabled. In the United States, and in many
other countries, a certain degree of willingness has
been demonstrated through the laws that have been
passed and by the considerable research that has
been done using all types of technology to design
aids to enhance the functioning of its disabled
citizens.
Beginning in the late 1970s, an important law
was implemented in the United States that directly
affects the use of microcomputers and electronic
assistive devices by school children who have
disa-bilities. This is Public Law 94-142, the Education
for all Handicapped Children Law, which requires
public education systems to provide a free and
appropriate education and related services to meet
the unique needs of every handicapped child. This
educational service is to be provided in the least
restrictive environment possible, an environment
in which a child with a disability can have access
to and interaction with nonhandicapped peers.
Sec-tion 602 of the law provides for the “use of
instruc-tional materials, including telecommunications,
sensory and other technical aids and devices,”
which are intended to help the child with
disabili-ties function more easily in the school
environ-ment.1 Public Law 94-142 has brought many
handicapped students, more specially trained staff,
and new educational techniques. So far, however,
there has not been much use of devices from the
biomedical, computer, or electronic industries. The
responsibility for making these devices available to
disabled children is not solely that of educational
systems, however. It is an area that should also
concern many other disciplines, including medicine
(pediatrics), rehabilitation engineering, physical
and occupational therapy, and speech and language
therapy, as well as governmental agencies and
so-ciety in general.
Suggestions have recently been made in the
pe-diatric literature that physicians taking care of
children, specifically pediatricians, should assume
a more active role in the educational process of
disabled children.2’3 As electronic assistive devices
for children become more available, these
physi-cians may be looked to for information and
opin-ions. These physicians should have a unique view
of the situation because they are more apt to see
the “whole child” in terms of the child’s personal
skills and needs as well as the family environment.
AVAILABLE DEVICES
There are basically three approaches to providing
electronic and/or microcomputer-based aids to
per-sons with disabilities. These three methods use: (1)
commercially available aids, (2) custom built aids,
or (3) modified commercially available “standard”
systems (Table 1). Until recently, the electronic
aids available to people with disabilities were of the
second type-custom built. These were usually
con-structed at rehabilitation centers at a high cost.
Fortunately, the increase in the availability of this
technology, in a general sense, has changed the
picture so that the first and the last approaches are
becoming more common. S
Each of these approaches has its own advantages
and disadvantages. Commercially available aids
have the advantage of being specially designed and
optimized to meet the needs of a specific class of
disabilities. In addition, maintenance of the
equip-ment is usually provided by the company. However,
there are two disadvantages: (1) the aids may not
meet individual needs because they must be
de-signed for a large category of people and (2) only
aids needed by a large number of individuals can
be produced economically.
The second group, custom-built aids, refers to
those assistive devices constructed to meet the
needs of one individual. As mentioned earlier, cost
of such aids is extremely high, because they are
usually one-of-a-kind, and maintenance and repair
are difficult.
The third approach, modifying or adapting
corn-mercially available and common electronic systems,
has some of the advantages and disadvantages of
the first two approaches. The use of
microcompu-ters as aids for the handicapped, for example,
adapt-ing an Apple microcomputer, falls into this
cate-gory. Devices such as microcomputers often are
easily adapted for a particular person with a
disa-bility by connecting various specially designed
switches or other electronic components that,
gen-erally, are readily available from several specialized
companies. However, as soon as more difficult
mod-ifications or additions are needed, modified systems
quickly begin to resemble custom-built aids and
also begin to take on the disadvanges of
custom-built aids in terms of cost and maintenance.
In this acticle, some commercial devices are
dis-cussed, as well as custom-built aids, in order to
demonstrate particularly useful or innovative
de-vices. A major focus, however, is to discuss that
group of assistive devices that involve modifications
or special uses of some type of commercially
avail-able electronic device, specifically microcomputers.
Much of the article pertains to devices for
physi-cally or communicatively handicapped children; it
TABLE 1. Examples of Available Electronic Aids
Disabling Conditions
Type of Aid Physical Communication Learning Hearing Visually
Commercial Feeding devices, environmental control
Direct selection aids, scanning aids, speech output
Computer or micro-computer
instructional software
Cochlear implant, sig-nal/alert devices, instructional soft-ware
“Reading machines,” Talking calculators, Mobility (object de-tection) aids
Custom-made Modified
wheel-chairs, “long-range optical pointer”
Manual
communica-tion boards (eg, Bliss symbols)
Custom-pro-grammed instruc-tional software
Modifications Keyguards, special
switches, keyboard emulators, voice recognition, adapted micro-computers
Speech synthesis, keyboard emulator, adapted microcom-puters
#{149}
Speech synthesis, special keyboard or joystick, graphics output, videodisc output
Signal/alert devices Speech synthesis,
is with these children that electronic assistive
de-vices seem to have the potential for the greatest
impact.
PHYSICALLY
HANDICAPPED
AND
COMMUNICATION
HANDICAPPED
CHILDREN
Physical and communication disabilities are
eas-ily discussed together because they very often occur
in the same individual and because the types of
electronic aids used for both are often very similar,
if not actually a single device that has multiple
functions. In addition, in most cases, the evaluation
process and procedures for prescribing these devices
are very similar. In this section, a broad view of the
term “communication handicapped” is used.
Chil-dren and adults who have moderate to severe
phys-ical handicaps involving the extremities always
have some type of communication handicap. These
communication problems mainly involve text
pro-ductiorl (written or typed), but many of these
chil-then and adults also have some vocal
communica-tion problems.
Children and adults with physical or
communi-cation disabilities have three alternatives when
faced with tasks that require manipulative or
com-munication capabilities. The first is to have friends,
relatives or attendants do these tasks for him or
her. The second is to conduct activities in such a
manner that these tasks are minimized. The third
is to be able to have independent personal
manage-ment of several, if not most, tasks by using assistive devices. The aids on which a person with disabilities
may depend can actually be changes made in the
environment such as ramps, wheelchair lifts, or
braille lettering in elevators. Often, however, the
most useful devices are those that are more
per-sonal.
Only so much can be done to the environment to
improve the life of physically or communicatively
handicapped children; eventually, changes need to
occur to help these children to adapt them to their
environment. In the usual therapeutic intervention
with these children, the focus is mainly to improve
upon their abilities. Therapists undertake programs
of both active and passive treatments to develop
useful functioning. Days, weeks, or even years may
be spent in helping children develop enough hand
and arm control to feed themselves independently
or to develop enough speech to be able to indicate
even simple wants. The use of electronic based aids
for physically handicapped or nonspeaking children
uses a different style of intervention. These two
differing approaches have been described previously
in a book by Goldenberg4 in which he calls the first
approach mentioned above the “exercise” model
and the latter style the “substitution” model. The
exercise model concentrates on rehabilitation
which attempts to normalize functioning. Speech
therapy and physical therapy generally follow this
model. The substitution model involves the
devel-opment of alternative means of communication or
control of objects, such as by the use of electronic
assistive devices.
Physical
Disabilities
As stated before, there are basically three
ap-proaches to the development of electronic aids or
systems for handicapped children. With devices in
all three categories the main issue is how a
handi-capped person can access the device-how is the
“input” made. Input consists of two components.
First, the actual hardware used (keyboard or
switches), and, second, how this hardware can be
used via a particular selection technique.
Vander-heiden and Grilley5 have described three categories
of selection techniques: direct selection, scanning,
and encoding.
Direct selection usually requires that either a part
of the person’s body (eg, finger, toe, elbow) or a
special device (eg, headstick, mouthstick) be used
as a pointing mechanism. The “pointer” makes
direct contact with either a regular keyboard or
other group of switches, a specially built keyboard
or some other device.
The simplest adaptation that can allow direct
selection is a keyguard, often used with a typewriter
or computer keyboard. Keyguards consist simply of
a first sheet of plastic or metal with holes drilled
out so that two or more neighboring keys cannot
be accidentally pushed at the same time. These
keyguards, of course, are useful only for those
dis-abled users who have mild to moderate impairment
of movements. Direct selection aids also include
enlarged keyboards, membrane switches, magnetic
or optically activated keys, or voice selection of the
keys by using an electronic voice recognition
sys-tern. Membrane switches that respond to minimal
pressure have been used quite successfully and are
generally lower in cost than other methods. Special
magnetic field-sensitive switches can be used in a
keyboard to respond to a magnet that is moved
around. A keyboard consisting of electronic
switches that respond to a focused light beam have
also been used to replace standard input devices
such as manual keyboards. Two commercially
avail-able electronic communication aids that use the
latter two types of switches, respectively, are the
“Autocom” and “Express” aids sold by the
Prentke-Romiche Company.
An interesting new approach to direct selection
is the use of voice input or speech recognition.
collect, process, interpet, and execute audible
in-structions. The systems that are available at the
present time, although highly useful, are
unfortu-nately still somewhat inflexible. One commercial
device is the Shadow Vet interface card for the
Apple microcomputer.6
Disabled persons with good head control but very
little purposeful motor ability in the extremities
have successfully used devices that employ light
sources on head straps in order to make direct
selections. In a recent project, Gundersen and
Vanderheiden7 used an Apple computer and a “long
distance” light pen called a “long range optical
pointer.” The system was set up to be usable as a
typewriter as well as a keyboard emulator for the
computer.
The second selection technique, scanning, is
more commonly used with severely physically
handicapped children and adults. In most cases,
input is made by controlling a single switch; this is,
therefore, usually the slowest selection technique.
The switch is either custom-made or purchased
from companies that produce this type of
equip-ment for persons with disabilities. Changes are
made in the switch or the way it is mounted so that
the user can easily activate it by a voluntarily
controlled part of the body. Switches have been
developed that can be fitted to many commercially
available electronic assistive devices. Trying to use
a single switch with a relatively complex electronic
device such as a microcomputer, however, might
cause considerable difficulties that may or may not
be solvable.
A group of devices known as “scanning
commu-nication boards,” which can be controlled by a
single switch, demonstrates how the scanning
method operates. These boards often can be used
as a remote control input device to a computer.
Several manufacturers, such as Zygo Industries and
the Prentke-Romich Company, make this type of
equipment. A light scans across squares on these
boards that contain pictures, symbols, or letters of
the alphabet and stops when a switch is activated.
The information or symbol on that particular
square, for example, the letter A, causes a signal
representing the letter A to be sent, for example, to
a computer or a printer. The types of switches that
can be used to control such a device can often be
activated by such slight movements as blowing or
sucking on a tube (pneumatic switch) or by minimal
contraction of a single muscle (myoelectric switch).
A third selection technique, encoding, is usually
used with microprocessor-based assistive devices
and is frequently used in communication aids for
nonspeaking children and adults. The main purpose
of encoding is to speed up the selection or input
process. Encoding is used with several commercially
available devices such as the Handi-Voice or Vois
speech output devices made by the Phonic Ear
Company. These devices use a voice synthesizer to
create an artificial voice. The voice synthesizer
produces words or phonemes-individual sound
units of speech. To produce words that are not
already stored in this device’s memory, the user of
this device can type on the machine’s keyboard a
series of codes for various phonemes. After all the
codes are entered, the artificial voice then “speaks”
the words or sentences. Voice synthesizer units,
which use some type of encoding system to
func-tion, are now available at low cost for most popular
microcomputers.8
As mentioned previously, microcomputers often
can be adapted to serve as useful tools for persons
with disabilities. One of the most important recent
advancements that deals with the adaptation of
microcomputers for physically handicapped
per-sons is the development of “transparent”
modifi-cations. These are modifications made by using
added-on equipment and/or specialized software so
that any piece of standard software such as
com-puter games, word-processing programs, or
corn-puterized instructional programs can be used.
Nei-ther the computer nor the standard software
pro-gram being used is disrupted or interfered with by
this type of modification. In addition, the computer
or software should not be able to disrupt or disable
the modifications in a truly transparent situation.
One group of currently marketed devices
dem-onstrates several ways of adapting computer
equip-ment by a transparent modification. Called
“key-board emulators,” they are electronic circuits that
allow a disabled individual to operate some type of
modified keyboard or other input device to
mdi-rectly access the microcomputer. Emulators
func-tion by taking the output from a special keyboard
or input device, altering this output appropriately,
and then transmitting a standard signal format by
wires to the appropriate connectors on the
micro-computer. The emulator translates the original
sig-nal into a different format that the computer
inter-prets as coming from its own keyboard. By having
a keyboard emulator, the special keyboard or input
device can be constructed or purchased to meet the
individual needs of someone with a certain type of
disability.
Keyboard emulators may become popular for use
in school systems. If they were used, disabled
chit-then could possibly have much greater access to the
microcomputers that already are available in their
schools. These school children would then be able
to use the same educational software programs as
emula-tor that works with the Apple computer is now
commercially available for a cost of approximately
$500. This emulator device, called the “Adaptive
Firmware Card,” was originally designed by Paul
Schwedjda in conjunction with the Trace Research
and Development Center in Madison, WI.9 Since
Apple computers are commonly used in schools,
this device, or a similar device, could play an
im-portant role in the education of disabled children.
Keyboard emulators would also be very useful for
a child who would be moving from one computer to
another, for example, from one at home to one at
school. The child could greatly benefit from the
flexibility provided by a portable, individually
se-lected or designed electronic device that used this
keyboard emulation technique.
In addition to multiple-use devices, such as
mi-crocomputers, there are also many single-use
de-vices designed or adapted for physically
handi-capped persons, ranging from electronic feeding
devices to elaborate environmental control units
which can turn on and off lights and appliances
and dial a telephone. One such extensive
environ-mental control device is the C2E2 control which
was developed at the University of Alabama at
Birmingham.’#{176}” The C2E2 device incorporates the
Shadow Vet interface card previously mentioned
which allows for the voice recognition technique to
be used. Other environmental control units have
recently begun to be marketed by such companies
as Prentke-Romich or J. A. Preston. Microcircuit
technology is also being used to improve electronic
wheelchairs, such as through battery monitoring,
programmable acceleration limits, and obstacle
avoidance 5ystems.’2
Communication
Disabilities
Applying knowledge of electronics to aid
corn-munication for the severely handicapped person is
not a new idea. Using electronic communication
aids has been reported since more than 25 years
ago in 1957’s Even with the increasing availability
of these electronic devices and despite the age of
some of them, they are not yet well known or widely
used for children. The development of electronic
communications aids is a tremendous achievement,
but there are still practical problems, especially
with regard to speed in comparison with “normal”
communication. Something even closely
approxi-mating normal speech production has yet to be
achieved and, unfortunately, this point has not
always been emphasized as it should be.
Spoken communication among nondisabled
in-dividuals is performed at such a high rate of speed
that few have the patience necessary to
communi-cate with a disabled individual using a slow manual
communication aid such as a lap-tray symbol,
let-ter, or word board. These boards are constructed
by printing words or symbols on a flat surface, and
they are used in face-to-face communication by
pointing to the words. Even though this method is
extremely slow, such boards should not be
aban-doned. As often as not, they are just as effective, if
not more so, as electronic devices in face-to-face
communication. Electronic devices are often
lim-ited by their need for some power source, all too
often a wall socket, which obviously limits the
usefulness of the device in many situations.
In the development of both manual and
elec-tronic devices for nonspeaking children, symbols
rather than words are often used in the
communi-cation technique. The use of symbols is especially
helpful if the individual does not know how to read
prior to using a communication board. Children
with significant mental retardation, for example,
may continue to use symbols as their only method
of communication as they grow older.
Normal children do not wait until they know how
to read before they begin to speak. Likewise with
children with disabilities, communication training
should not wait until the individual has learned to
read. Many nonspeaking preliterate children have
learned to communicate with others using systems
such as Bliss’4 symbols, an organized, but complex,
system of symbols that has been available since
1965. A Bliss symbol board is composed of an array
of symbols that is usually placed on a lapboard. A
child can send a message by pointing to one or
several symbols that communicate the intended
meaning. Symbolics, especially a system such as
Bliss symbols, is purely a graphic communication
system, and often true communication requires the
presence of an interpreter who is familiar with the
system and can translate the symbols into English.
Many types of electronic communication aids,
often incorporating the use of symbols, have been
designed to serve the disabled population. For
phys-ically handicapped children, these aids commonly
use the methods of scanning or encloding, which
have been previously introduced. Systems that
at-low direct selection are used with those children or
adults who have better control of movements. The
TetraScanner made by Zygo Industries and the
Omni (a two-sided scanner) sold by the
Communi-cations Research Corporation are but two examples
of several commercial devices that use the scanning
technique. The Autocom sold by the
Prentke-Rom-ich Company or the HandiVoice made by the
Phonic Ear Company (both mentioned previously)
are examples of dedicated communication aids that
\
Commercially available, dedicated
communica-tion devices have been found to be quite helpful,
but their use has been curtailed by their high cost
and limited flexibility. Recently, similar to what
has been accomplished for physically handicapped
persons, various projects have used some of the
common microcomputers as the basis of a system.
The use of a microcomputer as the central part of
the device has increased the versatility and
flexi-bility of these communication aids. Rather than
being used only for person-to-person
communica-tions, these adapted microcomputers can be used
for all types of communication-letter writing,
te-lecommunications with electronic mail, and other
more personal uses such as for environmental
con-trot or as safety and security systems. This
new-found flexibility in these “new-generation”
corn-munication devices is not necessarily due to the
sometimes extensive adaptations that are made to
the microcomputer but primarily due to the fact
that the typical microcomputer was not designed
for one particular use, but for use by many people
with many different purposes. Many of these
adap-tations use a certain degree of transparent
modifi-cations in order to successfully adapt the
microcom-puter.
Changes have also been made recently in several
of the commercially available dedicated
communi-cation systems, such as those listed before, to enable
these to act as input devices to many ofthe common
microcomputers. Some of these change have been
modifications that allow the device to serve as a
keyboard emulator to a microcomputer.’5
One example of how a computer can be adapted
to serve as a communication device is the use of an
Apple computer combined with a speech synthesis
device in the construction of a Bliss symbol
corn-munication device. A significant advance for Bliss
users, therefore, has been the development of the
“Talking Blissapple” program.’6 The computer acts
as the translator so that the output is in English,
“spoken” by the speech synthesis device.
A major barrier to using microcomputers as
corn-munication aids, ifthe intended user is significantly
physically handicapped, is the custom interfacing
needed to achieve optimum speed. Because using
custom hardware with standard computers can
eliminate many of the advantages of
microcompu-ters, care must be taken in deciding between
adapt-ing a microcomputer and purchasing a specially
designed but commercially available
communica-tion aid. The main advantage of using a
microcom-puter-based aid over most dedicated
communica-tion aids is the greater flexibility of a
microcom-puter. In particular, for children whose
communi-cation skills will continue to improve, it is usually
easier to change the amount and quality of the
available vocabulary in a microcomputer-based aid
than in most dedicated communication aids.
As previously mentioned, neither commercially
available, dedicated communication aids nor
adapted microcomputers can attain rates of
corn-munication that even come close to natural rates
ofperson-to-person communication. Even when
us-ing direct selection techniques with experienced
users who are nonspeaking but otherwise normal,
the rate of conversion is very slow-usually less
than ten to 15 words per minute.’7
One recent attempt to solve this problem of rate
is the development of new systems in which
sym-bols represent not just words or small phrases but
rather entire concepts. With these systems, of
course, some sort of extensive translation must
occur for effective communication with others to
take place. An example of this approach is
Mm-speak. Minspeak (minimum effort speech) is
essen-tially a new language designed for disabled persons
who cannot express themselves through speech or
hand signs. It is a “semantic interface,” which uses
microprocessor-based technology and speech
syn-thesis in a system that reduces the time and effort
required for communications.’8 A person using a
Minspeak board with fewer than 50 keys can
pro-duce thousands of sentences with usually fewer
than seven key strokes. Persons using Minspeak do
not even have to know how to spell; they can
produce complete sentences without selecting
let-ters, phonemes, or words. The symbols on the
Mm-speak board represent neither letters nor words but
generalized concepts. The Prentke-Romich
Corn-pany has recently developed a special “Express-3”
electronic communication aid that implements the
Minspeak concept. This unit uses a combination of
special microcircuits and a Vo-trax speech
synthes-izer coupled to the output of the microcircuits.
Because of the advances represented by Minspeak,
a multistate campaign has been coordinated to
pro-mote its use. Private and public health care funding
agencies have been approached in order to make
funding available for purchasing devices that use
Minspeak.’9
Another way to accelerate communication rate,
in addition to using a new “language” such as
Minspeak, is to improve the way in which a
partic-ular language, such as English, can be used.
Meth-ods are being developed that consider the statistical
nature of the English language so that previously
typed characters or words can be used to predict
what should follow.20
In regard to “spoken” output via devices that
of these devices. The number of words or phrases
that these devices can store is finite and the
gen-eration of new words by using phonemes is very
time consuming. Speech synthesis using random
access audio disc players or random access tape
recorders have been developed as one way of dealing
with the storage problems, but they present other
problems such as the difficulty in adding new words
or phrases to the vocabulary.2”22
Evaluation
(Table
2)
One of the first steps in evaluating the usefulness
of an assistive device for someone who is physically
and/or communicatively handicapped is to estimate
the time it would take to make the movement(s)
required to operate the device. For example, one of
the fundamental goals in selecting an electronic
communication device should be to increase the
communication rate. However, this rate cannot be
predicted only by looking at the features of the
device or even the abilities of the potential user.
The rate is a function of the interactions between
man and machine, which is different for each
per-son.
Because every disabled child’s needs and abilities
are different, it is important that the assessment
process and prescription of a communication aid or
any assistive device be done by knowledgeable
per-sons. To ensure that the device can be used
effi-ciently and will not interfere with other parts of
the child’s overall treatment or educational plan,
this process requires extensive planning by an
ex-perienced team of professionals who will evaluate
the child’s current and potential abilities.
Depend-ing on what the device will be used for, this team
might include such people as speech and language
therapists, physical therapists, occupational
thera-pists, rehabilitation engineers, physicians, special
educators, computer specialists, and others, who by
their training or experience are appropriate. This
interdisciplinary approach is in keeping with the
TABLE 2. Evaluation Process to Prescribe Electronic
Assistive Devices for Physically and/or Communicatively
Disabled Children
1. Select appropriate personnel to perform the
evalua-tions (interdisciplinary team approach).
2. Determine appropriate voluntary movement(s)
(eval-uate duration and consistency of movement). 3. Selection and trials for use of switch(es) and/or actual
electronic aids or simulators of electronic aids.
4. Positioning needs should be determined and
evalua-tions repeatedly performed.
5. Selection, funding, and purchasing decisions are made
for specific electronic assistive device(s) (concepts
to consider: personal, portable, affordable, and
speed).
mandates of Public Law 94-142. Also, this team
will usually provide the training and monitoring for
the child using an electronic assistive device.
The actual assessment process often relies solely
on having the child try out various devices;
how-ever, educated guesses based on prior experiences
with other children are often helpful. Systematic
trial and error evaluations have been successful but
can be very frustrating, especially considering the
time involved and the difficulty in obtaining a
sample of each device under consideration.
Ob-viously, as complete an assessment as possible
should be made prior to actually ordering
equip-ment so that devices that are unusable or that are
inappropriate are not inadvertently purchased.
Children with moderate to severe physical
limi-tations are the group that definitely needs the
corn-bined knowledge and experience of an extended
team of professionals. During the evaluation of a
child with such problems, the team’s main task is
to determine which movements a child can
consist-ently control and how these movements can be used
to control some type of device. In addition,
espe-cially with regard to communication devices,
deci-sions have to be made about which output method
would be the most acceptable and useful to both
the child with a disability and whoever will receive
this information. The output information could be
displayed on a television-like screen, typed out by
a printer, or presented as synthesized speech. Most
ofthe time, multiple output methods are preferable.
Probably the most important part of the
evalua-tion process, however, is the choice of input method,
or the type of switches that will be used with the
assistive device or communication system. There
are many types of control switches available for
various situations so that the selection can easily
be based on what is most appropriate to the person’s
needs and abilities. Several switching methods and
types of switches have already been mentioned.
Commercial switches have become more readily
available from companies such as Zygo Industries,
the Prentke-Romich Company, and J. A. Preston
Corporation, as well as several other companies.
Switch selection is sometimes a difficult task,
especially when working with severely disabled
in-dividuals who have very limited muscle control.
Fortunately, the vast majority of all disabled
chil-then have at least one muscular movement that can
be voluntarily controlled. Adequate time must be
spent to identify useful voluntary movements,
mea-sure the strength of movement (especially after
continued movements), and determine how the
per-son reacts to the output of the device (loud noise,
for example, may cause a startle reflex). The
before it can be used to point, push a switch, or
increase pressure. If durability is a major concern,
perhaps because of the presence of strong primitive
reflexes or dyskinetic movements, custom-designed
rather than commercial switches will sometimes be
needed. Systematic assessments are being devised
which, if proven successful, may facilitate the
por-tion of the evaluation process concerned with
se-lecting the appropriate switches.2325
Myoelectric switches may ultimately offer the
best course of control for some individuals,
espe-cially for those with particular problems such as
severe spasticity. The difficulties that some spastic
persons have in moving their arms are sometimes
due to interference by uncontrolled primitive
re-flexes. Such a person may be able to send a weak
neurosignal (myoelectric signal) that will not evoke
reflex reactions but still be recognized by an
elec-tronic sensor. Obviously, only a few such switches
could be used and they would have the definite
disadvantage of being directly connected to a
per-son’s body. This would be inconvenient for the user
and would also require an assistant to be readily
available to attach and remove the myoelectric
sensors. Methods involving myoelectric switches
have been described in the past by Vanderheiden26
of the Trace Research and Development Center.
Successful projects have also been made using
electronic eye tracking systems that can function
as switches.27 Eyes, however, work more
appropri-ately as input mechanisms, not as output
mecha-nisms, and electronic aids relying on eye tracking
will usually restrict where a person can look while
using such devices. Nonetheless, there appears to
be great potential for using these “eye-gaze”
sys-tems with persons having severe motor handicaps.
The popular joystick, which is part of nearly all
video game machines, can also be used quite
effec-tively as a type of multiple-switch input device.
Joysticks are often employed when scanning
tech-niques are used to help increase speed of input.
Because using switches to control a device
re-quires an overt movement by some part ofthe body,
sometimes this movement causes serious and
diffi-cult logistical problems. For example, how a person
is positioned relative to the device is an important
factor that should always be addressed. When
chit-then are evaluated, extra care must be taken in
determining proper positioning and finding the
most appropriate motor movement. There are two
reasons for this. First, the child must not become
frustrated because the movement is too difficult or
too inefficient. Second, the extended use of
abnor-mat reflex patterns of movements may actually lead
to or worsen significant physical deformities, such
as contractures or scoliosis.
Many children with severe physical handicaps
have difficulty maintaining a position that allows
optimal functioning. Most require special seating
devices or wheelchair inserts that help control
ex-traneous movements or prevent abnormal reflexes.
Proper positioning improves stability and control
of muscle movements, thereby allowing them to
more easily maintain their attention. They are then
able to work with an electronic system with less
effort and energy being expended in trying to keep
an adequate position in relation to the device.
Selection
of Specific
Devices
Four concepts have recently been introduced by
Thomas2’ that pertain to predicting long-term
use-fulness of electronic communication devices. These
concepts can apply as well to electronic devices
designed for children or adults whose primary
prob-lems are physical handicaps. These concepts are
personal, portable, affordable, and speed. These are
important qualities that should be addressed during
the selection process for any electronic aid or
as-sistive device. “Personal” means that the device
should be able to be operated without assistance
and that it belongs to one person and is not shared
with others. “Personal” also suggests that the
de-vice can be individualized as much as possible.
“Portable” implies that a person need not always
be near a wall electrical socket and that battery
power is used. Portability is becoming less of a
problem because the technology that has brought
“lap-sized” portable microcomputers to the general
public is being used to improve the design of
elec-tronic aids for disabled persons. Affordability is a
complex issue, mainly because these devices are
sometimes paid for by third party payers. Most of
these devices are very expensive, especially if they
are custom-modified for a particular person or if
nonstandard components had to be used. In a
prac-tical sense, the only way to lower the cost of these
devices is to produce them commercially. This is
the reasoning behind using standard
microcompu-ters, which can often be adapted for a relatively low
cost. Funding issues are further addressed later in
this article. The concept of “speed” deals with the
fact that each potential user has different physical
and mental capabilities and that different devices
often vary significantly in ease of use despite their
having the same purpose. The evaluation process
should always determine ways of maximizing effect
while minimizing the effort of the person using a
device. Speed is especially critical with
communi-cation aids because the successful use of the aid
depends on significantly increasing the person’s
LEARNING
DISABILITIES/MENTAL
RETARDATIONThe vast majority of children who have special
needs are not physically or sensorily handicapped
but have difficulties in learning-for example, with
reading, writing, or computational skills. Although
the needs of these children are usually covered for
the most part by special education services, medical
input into possible diagnosis or treatment of
prob-lems is often. sought. This medical input occurs
frequently with such problems as learning
disabili-ties or with attention deficit disorders for which
stimulant medication is sometimes recommended.
This medical input may also require that an opinion
be given about the appropriateness of certain
ser-vices or equipment.
As has already been presented, various electronic
devices are being used in several ways to remedy
some of the handicaps that accompany various
disabilities. With children who have learning
hand-icaps, the greatest potential benefit of this
elec-tronic technology seems to be the various ways that
microcomputers can change the delivery of
instruc-tion.
As an aid to teaching a learning-disabled child,
microcomputer-based instruction has several
unique advantages, perhaps the most significant of
which is the ease of individualization. There is a
wide range of variation in the learning problems of
learning-disabled children. It seems possible to
build on the children’s strengths and talents and to
develop alternative ways of learning by using
mi-crocomputers. Individualization of the level of
in-struction for a microcomputer software program is
also possible through flexible branching in the
pro-gram.
Another advantage is that microcomputer
edu-cational programs use an interactive medium which
provides students with immediate feedback
regard-ing performance. This prevents the handicapped
learner from practicing wrong responses until the
teacher can provide remedial instruction. Properly
designed microcomputer material is also self-paced.
The learner can cover the material as rapidly or as
slowly as needed and can review it as well.
Micro-computers also serve as important motivators for
learning-an important factor in teaching some
children who may need additional motivation
be-cause of frequent and repeated failures. Very few
children with learning disabilities have their own
personal teacher on a full-time basis. The use of a
microcomputer allows these children to begin to
develop independent learning skills.
A child with learning disabilities usually does not
have any obvious or significant physical handicap,
but often changes need to be made in the
microcom-puter hardware or the way information is displayed.
For instance, children with dyslexia or severe
read-ing disabilities might need to use some other form
of input device to a microcomputer other than a
conventional keyboard. These children would have
problems recognizing the correct letters, would
quickly lose interest, and their attention would
wander. Many devices can be creatively used in
such situations to replace keyboard entry; joysticks
and graphic tablets are but two examples.
On the output side of this computerized
instruc-tional environment, presenting words on the
corn-puter screen is inappropriate for certain ages or
different types of learning problems. Graphic
rep-resentations or pictures have been shown to provide
motivation as well as instruction. Recently,
video-disc players have been coupled to computers to
teach various skills to mentally retarded
nonread-ing chilthen. Voice synthesized output, a less
ex-pensive output option, also has been used.
Some limited research has been done to address
the usefulness of microcomputer-based learning
en-vironments for teaching learning-disabled children.
Several studies are currently underway that will
hopefully answer some important questions.
Re-search has already shown that some features that
are often incorporated into educational software,
such as sound effects, can cause problems when
used with certain learning-disabled children.3#{176}
Several years ago, studies done at Johns Hopkins
University informally evaluated educational
soft-ware for learning-disabled students.3’ A number of
interesting observations were made. First,
corn-puters seemed to be able to motivate even the most
unmotivated student, although whether this would
be true after years, rather than weeks, of exposure
remains to be seen. Second, parents reported
posi-tive attitude changes in their children; most of these
children became somewhat upset when the study
ended. Third, teachers and children agreed that
commercially produced programs intended for
in-structional purposes were poor. The teachers,
how-ever, considered instructional computer programs
that had been written by Hopkins’ faculty
mem-bers, specifically for use in the course, to be very
useful. Surprisingly, despite a minimum of
instruc-tion, these children were also found to be able to
write simple computer programs which indicated
the presence of a previously unrecognized high-level
cognitive ability.
On the other hand, several reports indicate that
there is, at present, still no hard evidence
demon-strating the effectiveness of computer-assisted
in-struction with disabled children.31’32 Often, the
re-views dealing with computer-assisted instruction
have seemed to be based on opinions and
not reported, there are usually small numbers of
subjects, and faulty methods are often used which
weaken the quality of the results. A recent complete
review of the literature, done by Mason33 as part of
a doctoral dissertation, concluded that, for learning
disabled and mildly mentally retarded students,
“there is much hope for the effectiveness of CAl
[computer-assisted instruction]. . . but not much
proof of it.”33
Microcomputer instruction is obviously not
at-ways appropriate. It is not a panacea for learning
disabilities and should not be used without planning
and consulting educational specialists. The
educa-tional problems of handicapped students should be
examined first, and then technology can be applied
where it can effectively alleviate those problems. In
the past, many microcomputer-based instructional
problems have been deficient and improperly
de-signed. This occurred because some of software that
had been produced was designed not by educators
but by computer programmers. This situation is
changing as educators become more involved in the
development of programs.
SENSORY DISABILITIES
Because the transmission of impulses through
the nervous system is electrical in nature, it should
be possible, in theory, to replace the functioning of
some damaged nervous tissue with an electronic
substitute. Although this replacement cannot be
done at present, many electronic and
microcom-puter-based devices can reproduce or enhance
sen-sory abilities for those children and adults who have
sensory handicaps. One example is hearing aids,
electronic devices that have been around for years
but that continue to be improved because of the
changes in technology. Many new possibilities for
“neuroprostheses” or sensory prostheses are
cur-rently being researched or are just now being
din-ically used. The areas most often researched are
concerned with devices constructed to help those
with hearing and/or vision impairments.
Data recently released from the National Center
for Health Statistics demonstrate the prevalence of
these impairments. In children younger than 17
years of age, significant hearing impairments are
present in about 18/1,000 persons in the United
States (approximately 650,000 children total).
Se-vere visual impairments in children younger than
17 years are present in 9.7/1,000 persons
(approxi-mately 380,000 children total).
Hearing Impairments
An example of how high technology has already
helped hearing-impaired children is the
introduc-tion of the cochlear implant, which shows promise
of being an important therapeutic device for some
types of hearing impairments.tm The cochlear
irn-plant works by direct electrical stimulation of the
auditory nerve. Therefore, there is transmission of
electrical impulses even if the cochlea is damaged.
The technology of microprocessor circuits is being
used continually to improve the functioning of this
particular device.
Without going into detail about the various
phi-losophies or styles of teaching hearing-impaired
children (for example, sign language v oral
ap-proach), it is worth mentioning that there are many
projects completed or currently underway that
in-volve electronic devices for children with this
dis-ability. Some examples of projects that have been
done include computer-based instructional
pro-grams to help teach lip reading or sign language
and for speech training.36’37 Safety or alerting
sys-terns have also been developed that flash lights or
use vibration as signaling rnethods.m
Visual Impairments
Children who are blind, visually impaired, or
severely reading disabled often have problems
par-ticipating in many educational or recreational
ad-tivities because they are unable to acquire
infor-rnation from written text. Although this problem is
to some degree alleviated by materials that are
printed in large type, or Braille, or that are recorded
on records or cassettes, most written material is
not available in these forms. For those who cannot
read written text, electronic technologies have led
to an important innovation which is called a
“read-ing machine.” The most widely available
commer-cial device of this type is the Kurzweil Reading
Machine, which links microprocessor, optical
scan-ning, and voice synthesis technology.39 The
Kur-zweil Reading Machine, because it sells for more
than $15,000, is a device usually shared by many
users, such as in a library. It converts books,
mag-azines, letters, or any printed material word by word
into spoken English at a rate that is comparable to
normal conversation.
Many other less expensive devices are the
prod-ucts of recent technologic advances and are
de-signed to aid visually impaired persons. Various
talking computer terminals are available such as
the “Total Talk” computer terminal.40 There are
also talking calculators, such as the “Speech Plus”
talking calculator, which costs significantly more
than a regular calculator but is still relatively
in-expensive.4’
Microelectronics has also allowed the
blind that converts an optical image of a printed
character or figure on a page of an ordinary book,
or magazine, into a vibrating tactile reproduction.
A visually impaired child whose fingertips are
rest-ing on the device can then feel a vibrating image of
the original printed character or figure.4’
For those children or adults with visual
impair-ments who use the braille system, microprocessor
technology has led to the development of
“paper-less” braille devices. The best known, perhaps, are
the VersaBraille devices, costing about $5,OOO.4142
This device uses a standard audiocassette that
al-lows recording and playback as it displays braille
information. It can also serve as a braille computer
terminal. For visually impaired children or adults
who are able to read large print, electronic devices
have been developed that greatly enlarge on a
tel-evision screen the words and characters coming as
output from several types of microcomputers or
from printed material, such as books.4”43
Different types of sensors using sound or laser
beams are becoming available to help the visually
impaired person achieve more independent
mobil-ity and awareness of their surroundings. One such
device is the Mowak sensor, a hand-held mobility
aid that uses a narrow beam of reflected
high-frequency sound that produces vibration in the
sensor when the sound is reflected from an object.4’
A similar device, the Sonicguide is currently being
used with congenitally blind infants to help them
gain some awareness of objects around them.4’
For deaf-blind persons, devices are also being
developed that may improve their overall ability to
communicate. One commercial device, the
Tele-Braille, is very similar to the VersaBraille but is
linked either by direct wires or through telephones
to a display terminal that is used by sighted
per-sons.” Information put in at either end would
ap-pear simultaneously as words on the visual display
for the sighted person and as braille characters on
the braille display for the deaf-blind user.
CONCLUSIONS
-Severe disabilities in children, whether physical,
sensory, or related to learning, invariably disrupt
the normal patterns of child development. The
terms “developmental milestones” or “educational
milestones” promote the common image of child
development and education as being some long road
that must be traveled successfully. However, as
Tobias,44 a specialist at the Matheny School for
handicapped children, eloquently put it, “the
disa-bled child is obviously presented with higher tolls
and lower gas mileage on this trip.”
The use of electronic aids, adapted
microcompu-ters, and special computer-assisted instructional
programs for handicapped children has led to an
alternate routine so that often these milestones are
not as important. This alternative, “substitution,”
approach is also very different from conventional
therapy or the “exercise” approach, such as with
physical therapy, which attempts to find treatments
to allow these milestones to be crossed. It should
be stressed, however, that both of these therapy
modalities are always necessary, especially with
physically handicapped children. They are not
mu-tually exclusive but often are assistive to each other.
As an example, when the evaluation and selection
of an assistive device for a physically handicapped
child is individualized carefully, therapists can help
to train and encourage voluntary movements from
the handicapped child that will not only allow
ac-cess to an electronic assistive device, but will help
him or her practice muscle movements that can
later be used as part of more complex movements
such as self-feeding.
The electronic and microcomputer revolution,
although increasing the production ofprograms and
devices that are usable to handicapped people, has
the paradoxical potential of widening the gap
be-tween handicapped and normal persons.
Opportu-nities for computer-related professions are
increas-ing, but unless proper provisions are made, persons
with handicaps will have increasingly less of a
chance to compete for these jobs when compared
with the nondisabled population.
One way to improve future opportunities is to
ensure that handicapped children have access to
appropriate devices so that they will be well
prac-ticed by the time they are adults. Improved access
to these devices also has some probable social
im-plications. As handicapped children become better
able to use their assistive devices and/or
commu-nication devices, they most likely will become less
isolated and have more contact with the
commu-nity. On the other hand, it is up to the
nonhandi-capped members of society to see that the
expen-ditures and efforts that have been made will
con-tinue to be expanded to include more children and
adults with handicaps. With society’s assistance,
some persons with handicaps will themselves
be-come productive rather than dependent members
of society.
Funding
Issues
Funding issues are often more of a concern when
dealing with devices for physically,
communica-tively, or sensorily handicapped children rather
than with those devices for learning-handicapped
micro-computers and software that are being used
exclus-viely by their learning-disabled students. In
addi-tion, educational needs are not considered
“medi-cally necessary” and are, therefore, generally not
fundable by insurance or government agencies. The
other handicaps listed above involve much more
than educational needs and, therefore, with careful
planning, proof of “medical necessity” can
some-times be provided to a government agency or
third-party payer which will then pay for part or all of
the equipment. Charitable agencies may also be
willing to pay for electronic assistive devices,
espe-cially if the need is perceived to be great; therefore
some of the following points will also be applicable
to obtaining funds from these organizations. During the initial assessment process,
affordabil-ity of the device(s) frequently can become the key
issue. A high cost, greater than $500 or $1000,
makes the device unavailable for most handicapped
children, especially if their families have to pay for
it themselves. The market for these devices is
ob-viously limited, production low, and availability
somewhat random. All of this leads to high prices.
Adapting standard microcomputers, or other
corn-mercial equipment, as previously noted, allows
lower costs because of the mass-market nature of
this hardware and the competition between
corn-panies. Using standard components also makes
re-pairs and maintenance easier. Adapted hardware,
however, is useless for some handicapped children
and adults, and for some types of disabilities.
Many of the false impressions concerning these
devices are directly related to funding, especially
funding from government or other third-party
sources. These issues have recently been
summa-rized by Vanderheiden.45 Although specifically
ad-dressing microcomputers, his statements can apply
to other electronic assistive devices as well. In
Van-derheiden’s opinion there are three common
prob-lematic impressions: (1) “the view of technology as
a cure,” (2) “the view of a microcomputer as a
toy”-a view that very often applies to other
elec-tronic assistive devices, and (3) a “ lack of good
application and delivery system for technical aids
in general and for microcomputers in particular.”
With regard to the first impression, that
“tech-nology is a cure,” government health programs and
third-party health programs certainly prefer to
pro-vide reimbursement for durable medical equipment
that immediately helps the patient. The benefits
from electronic assistive devices may not be so
immediate, but tremendous benefits may occur for
a child or adult after months or years of use.
Al-though these benefits may result from actual
im-provernents in physical health, they are more likely
due to improved mental health, self-esteem, and
independence.
Some people see electronic devices designed to
assist disabled people as expensive “toys,”
espe-cially when these devices involve an adapted
micro-computer. Unfortunately, some funding agencies
would pay for an expensive custom-made
comput-erized device for a handicapped child but would
refuse to pay for a much less expensive and far
more flexible adapted microcomputer system.
The third false impression is probably the one
that can be most easily corrected. Changes in the
evaluation and delivery system of these assistive
devices must come from those professionals who
are working with handicapped children. The
fund-ing agency must believe that the equipment is
nec-essary and that the child has been properly
evalu-ated. What has happened in the past, especially in
the absence of proper assistance and evaluation, is
that some adapted microcomputer or assistive
de-vice has been purchased with financial assistance
from an outside source, such as a government
agency, but the person is unable to use the device
or it is found to be totally inappropriate. When this
occurs, funding agencies become increasingly more
reluctant to fund such devices.
Demonstrating conclusive need is not always
enough, however. Research done by the Office of
Technology Assessment (a US Congress agency)
has shown that “a number of disabled people are
denied funding for particular technologies that are
clearly appropriate.” In addition, this agency has
found that, in instances in which funding was
ob-tamed, “services for their proper use (eg, fitting,
training in their correct usage, and maintenance)
are often not included in the funding.”46
Securing funding for purchase and training in the
use of these devices is not an easy task in these
days of frequent budget cuts and lack of expansion.
To borrow a term from the real estate agencies,
“creative financing” is what is needed at present.
We will need to become more sophisticated to
ob-tam funding for even the simplest devices.
Solu-tions to the funding problems are unclear, but
sev-era! inroads have been made. Literature is available
that focuses on the specifics of funding for
de-vices.46’47
Pediatricians and other physicians are often
called upon to send letters or prescriptions to
fund-ing sources in order to help obtain funding. In most
cases, this correspondence should be written only
after conferring with several different therapists
who have evaluated the child in order to get as
much information as possible. Complete
informa-tion, in this sense, dose not mean a complete report
of the physical examination findings or treatment,
but rather a presentation of the findings that would
be of most interest to the funding agency. As one
