Assistive Technology for Individuals with Developmental Disabilities (DD) or Traumatic Brain Injuries (TBI)

Developmental disabilities (DD) and traumatic brain injury (TBI) both impact cognitive functioning. Technology can help meet the needs of both groups, whether by compensating for non-technical skills or by making technology itself easier to use. 

Definitions

While the term “developmental disability” technically refers to any disability that originates before age 18, it is often used to refer specifically to cognitive disabilities present from birth or a very young age. Down Syndrome and Fragile X Syndrome are common types of DD caused by genetics; people with birth injuries such as cerebral palsy (CP) may also have cognitive disabilities, although most people with CP have standard intelligence.

Per the Brain Injury Association of America, TBI is acquired after birth and is caused by an external force (as opposed to an internal force, such as a stroke). TBI is also sometimes called the “signature” injury of the Iraq War.  It may affect cognition as well as coordination, vision, and speech. Accommodations for TBI and other acquired cognitive conditions are usually similar. 

The main difference between technology users with DD and those with cognitive disabilities acquired later in life is that the former group is less likely to have prior experiences and skills to build on. This is not to imply that people with DD are unable to learn or intuit technical concepts; for example, the Center for Accessible Technology has worked with an adult artist with Down Syndrome who easily figured out how to use MacPaint to accomplish a specific drawing goal. 

Learning disability (LD) refers to a condition where people have standard or above-average cognition, but have difficulties with processing information. The accomodation strategies are often quite different than those for people with DD or TBI; the ATC article on assistive technology for people with LD provides suggestions. 

Although autism is a developmental disability and much of the technology in this article may be of help to people with autism spectrum disorders, additional accommodations may be needed. Information about specific accommodations for people with autism is provided in the ATC article on Assistive Technology and Autism.

Overview

People with DD or TBI tend to benefit from solutions that are simple and perceived as relevant to their needs. Use of pictures instead of or in addition to text may also be beneficial.

There are three primary ways that technology accommodations can be important for people with DD or TBI. Technology can help with daily living needs, such as scheduling. It can compensate for difficulties using standard technology such as computers, mobile devices, etc. It can also provide aids for communication, as addressed in several ATC articles about augmentative and alternative communication (AAC)

Daily Living Technologies

Daily living tasks where technology can be particularly helpful include memory, task analysis, and cognitive training/retraining.

Memory Aids

Individuals with DD or TBI may need assistance with remembering scheduled events, regular activities (e.g., taking medication or paying bills), sequencing (e.g., the order in which to put on clothing), and the identity of objects or people.

Mainstream technologies that can be of use include the following:

  • Very small (keychain size) devices such as My Li’l Reminder can record up to 60 seconds of audio that can be retrieved as a reminder of to-do items or other important information.
  • Label makers such as the Brother PT1290 can be used to produce labels that will identify the name and purpose of objects that the individual has trouble recalling.
  • Talking watches such as the Radio Shack Talking Watch, or watches designed for blind individuals, can be used as discrete portable reminder systems.
  • Photo phones such as the Geemarc Amplified Telephone can be used to associate a picture with a speed-dial number to help users remember who they want to call. 

There are also technologies that have been specifically designed for use by people with DD, TBI, or similar conditions, including the following:

  • B.A. Bar is a barcode reader that works with programmable barcode labels. The labels “are glued onto objects or symbol panels; scanning enables voice output….helping the user to identify objects, compensating for word finding difficulties and assisting with learning correct syntax.”
  • First Then Visual Schedule is an app for the iPhone/iPad/iTouch that allows creation of sequencing for basic daily living activities. A picture library is included, and descriptive audio can be added to items.
  • Mem-X is a simple digital recorder with some advanced features. “The front side of this palm sized device has a single good sized button and speakers for listening to messages and the back is where the recordings can be made. Underneath a flip up cover there are input keys for day, date and time, and the amount of repeats needed or whether it is just a one off message. The recording can be 10 seconds long and 90 messages can be held in the device.”
  • The Planning and Execution Trainer (PEAT) is a highly customizable handheld device for assisting with scheduling and task analysis. It also provides feedback: “After PEAT cues the user [to perform a task], it then monitors their response to detect problems and adjust when necessary.“

Task Analysis

Task analysis is the process of breaking a large task into smaller components. For example, “separating an egg” is a large task that can be broken into picking up an egg, tapping it against a bowl until it cracks, separating the two sides, identifying which side has the yolk, shifting the yolk to the other side, etc. This analytical process can be difficult for people with DD or TBI.

Both mainstream and custom software exist to help with task analysis. For example:

  • TaskArchitect is a mainstream software program that allows steps of a task to be broken down using an outline format. The outline can then be converted to a flow chart, which may be easier to follow. You can download a free trial version.
  • Picture Planner is visual scheduling software that allows multiple images to be associated with seven task-related categories: what, who, where, how, cost, bring, and clothes. The software is available for both Macintosh and Windows, and can be synced with mobile devices.
  • WayFinder is a mobile device that allows creation of customized route information to assist with traveling. “With WayFinder, specific travel routes can be created, then activated from the GPS location. Users then receive customized audio and visual instructions to prompt them through route navigation.”

Cognitive Training and Retraining

Cognitive training for people with DD helps them learn basic skills, such as cause-and-effect sequencing. It can also provide more accessible way to learn the same skills as their peers, such as turn-taking, self-care, and reading. The ATC has an article on cognitive training software that provides more information. 

According to the American Brain Tumor Association, cognitive retraining for people with acquired cognitive disabilities generally has two goals: regaining skills and compensating for skills that cannot be regained. They suggest a variety of simple no-tech strategies such as puzzle books, strategic games such as Uno, checklists, and simulations of real-world items, such as a grocery shelf. Low-tech strategies can include the Attainment Talking Photo Album, which allows audio to be recorded and associated with pictures from the user’s past.

Cognitive training/retraining software may be designed specifically for people with cognitive disabilities or for a more general audience, such as elders. While research does not yet provided a clear picture of how software provides better training than lower-tech methods, its advantages may be manifest in individual experiences—e.g., users may engage with the software for longer periods of time than with paper-and-pencil puzzle books. The Rainbow Rehabilitation Centers suggest several hallmarks of quality to consider when choosing cognitive retraining software, including being supportive and non-judgemental, easy to use with minimal support required, customizable, interesting, and providing useful clinical data; these are relevant to training software as well.

Accommodations for Technology Use

Since much of computer use involves memory and task analysis, individuals with DD or TBI may have difficulty with these. Solutions tend to be idiosyncratic and may take some trial and error to discover. Below are some case studies from our experience:

  • Andrew is a young man whose life before and after his brain injury centers on his family. He was not able to identify keys on a standard keyboard for typing. We set up an Intellikeys keyboard overlay and asked him to specify pictures that he wanted associated with each key—e.g., “D” used a photo of his uncle Dave, and “K” used the logo from KPRA, a radio station he likes. We also used an inexpensive program called Sounding Keyboard and Mouse that permits audio files to be played when a key is pressed. Andrew was able to identify keys more easily using this setup, and the audio feedback provided reinforcement.
  • Miranda is a middle-aged woman whose TBI severely impaired both her memory and patience. We found that speech recognition software helped her write with satisfactory accuracy, and that the Ginger spelling/homonym checker helped her proofread her dictated text. 
  • Gracie is a young adult with DD who would very much like to use word processing. She responds particularly well to software that addresses her by name. We used Write:Out Loud, a talking word processor, and typed in encouraging prompts such as "You're doing great, Gracie! Can you write about what you had for breakfast?" Gracie was then able to hear both the prompts and the text that she was writing, which she found motivating.

Some people with DD or TBI may wish to use computers but need an alternative to standard technology. Alternative strategies include the following:

  • Mobile devices, which do not require constant connection to an electric source and may have less “flicker” than computer screens, may be preferred by some people.
  • Services such as email2phone convert emails into voice mail, so that users can retrieve messages in an audio format without needing to use a computer. They may also allow the user to send an audio message that is converted to email.
  • Celery and Presto are two services that allow email messages to be received via a fax machine. Celery also permits users to write out a reply, fax it, and have it delivered as an email attachment.

The Future

New touch-screen technologies such as the iPad have permitted development of a wide range of apps useful to people with DD and TBI for communication and assistance with daily living tasks. Because they also have access to the Internet and can provide other computer functions, they can become an all-in-one portable solution for meeting some people's needs.

Much of the current research on technology for people with TBI is focused on medical functions such as improved diagnostics. However, there are at least two promising assistive technologies currently being developed:

  • In-Vehicle Assistive Technology (IVAT) is being designed at the Georgia Institute of Technology as a way to provide real-time assistance to drivers with TBI. The system provides positive feedback when the driver indicates that they have performed critical tasks such as checking the mirrors, and tracks performance for the benefit of evaluators.
  • Brain-Computer Interfaces (BCI), which have great promise for people with paralysis, may also be a useful input method for people who have language processing difficulties.

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