DIGITAL ASSISTIVE TECHNOLOGY: THE UNIQUE CONTRIBUTION OF OCCUPATIONAL THERAPISTS

digital assistive technology      Digital technologies have become a huge part of our everyday lives. Whether we embrace or resent this fact, in Western cultures it has eaten into a big portion of our ‘doing’ time, and even some of our ‘being’ time (we can even unwind!). For people of all ages, genders, abilities and cultures, digital technology has made it possible to communicate from great distances, to interact socially and network professionally, to share relevant and irrelevant information, to watch videos, to listen to our favourite music, to be entertained, to play, to shop, to learn new things, to organise our lives, to capture good times, to remind us of essential things, to collect and categorise things, to become more productive, to relax, …  the list of functional applications is endless.

Children as young as two are confident in the use of a mobile phone or tablet, and request this on a regular basis from their parents. People in the UK spend a daily average of 2hrs and 52 mins online, with mobiles and tablets taking up to 56% of internet time (IAB & UKOM, Sept 2015).Time spent online infographic.JPG

The routine use of computers, mobile phones, tablets and other gaming devices has become part of our daily routines and we cannot easily imagine our lives without such gadgets anymore, regardless of whether we feel they are becoming more intrusive or helpful than ever.

However, in our OT roles and daily clinical practice we can over-focus on traditional activities of daily living and forget the digital field, or categorise it as an additional, non-essential occupation. How many times we hear OTs ask questions about washing & dressing, feeding, cleaning, preparing food, using public transport, managing money or anxiety when outdoors, but we rarely feel we need to hear about the person’s engagement in digital technology. ‘Can you use your mobile phone, laptop computer, kindle reader, iPad, music player, TV, Xbox…?’ ‘Is this currently an important part of your life?’ Such an essential and ubiquitous occupation is not measured by standardised assessments and rarely appears in questionnaires and initial interviews.

We set clear limitations to our clinical roles when we fail to consider that we could be helping someone access regular digital technology, and furthermore, we could use that technology to make their everyday lives easier. With the exception of services dedicated to the provision of AAC (Alternative and Augmentative Communication) devices or environmental controls, OTs can often shake any responsibility to address participation or use of digital technologies as essential tools in their interventions. Worth noting that this is not always the case, as some exceptions to this rule are available within the profession.

In this opinion piece I would like to advocate for the unique role that OTs can have in the assessment, provision and general use of digital technologies as part of their roles in any clinical areas, and why they should develop their skills in understanding and applying such technologies to their daily practice.

Unique Role of the Occupational Therapist (OT)

Through the use of digital assistive technology, OT professionals can facilitate participation in the following functional areas (some examples below):

  1. Recording, organising and categorising concepts during lessons or throughout the work day – i.e. as an alternative to handwriting, a student with movement difficulties can use ‘dictation’ software. Another person with dyslexia at work can use specific software and a laptop to assist with the mind-mapping of ideas or to organise their daily schedule.
  2. Access to educational activities – i.e. helping a persostudent and iPadn with visual impairment to read and interpret printed visual information at university through the use of a digital video magnifier or adapted laptop settings.
  3. Access to play and leisure activities – i.e. facilitating access to a gaming device such as an Xbox for an adult with a recent spinal injury.
  4. Access to communication activities (often in collaboration with Speech and Language Therapists) – i.e. assisting a student with severe dysarthria and movement difficulties to communicate verbally in a lesson through the use of adapted communication grids on an iPad.
  5. Engagement in social activities – i.e. helping an isolated elderly person to access social media to keep in touch with far-away relatives and friends; or showing a person with chronic pain how to access condition-specific online forums; or practicing social skills with a person with autism by watching online videos or making social stories on an app.
  6. Access to environmental controls – i.e. helping a person with a deteriorating condition (i.e. MND or Muscular Dystrophy) control their TV, house lights / temperature/ music through a tablet device and an adapted switch.
  7. Maintaining independence skills at home (including Telecare) – i.e. helping a person with dementia stay at home by installing sensors in the bedroom or placing regular medication reminders on their mobile phone; or assisting a young person with autism to follow visual schedules of their morning routine on an iPad app.
  8. Long-term condition management – i.e. helping a person with diabetes monitor their blood sugar levels and food intake through a specific iPad app; or assisting a person with a mental health condition to monitor their lifestyle and habits through a mobile phone app, by including their exercise routines, daily reminders, log books, mindfulness activities, etc.

Basic OT competencies in the use and provision of assistive technology have been outlined by the AOTA (2015). OT’s unique contribution to the assessment and provision of digital technology includes knowledge and expertise in the following areas:

  • Seating and positioning to encourage the best possible posture in preparation to access technology. Additionally, OTs are confident setting up and adjusting specialist seating and mounting systems to achieve an optimal environment for technology use.
  • Understanding of upper limb and hand function, and carrying out interventions to maximise this ‘access option’ first.
  • Knowledge of developmental milestones, relevant anatomy, physiology, kinesiology and medical conditions, their prognosis and occupational impact on the person. This enables an accurate assessment of physical access to technology, and accurate selection of long and short term options for the user
  • Sensory processing differences and other sensory needs (i.e. visual perceptual difficulties, auditory loss, etc.) can be identified and addressed in more complex cases, if they have an impact on the technology being tried.
  • Expertise on activity analysis to enable participation in a range of daily activities, ensuring an ergonomic fit between the technology and the specific needs of the user.
  • A holistic and client-centred view of the person, considering the best integration of the environment, the person and the occupation or activity, as part of our professional identity and practice models (see below).

PEO Model

Through our own daily interactions and experiences with digital technology we are able to understand how it can be adapted and customised to meet individual needs. At the end of the day, we often change and adapt this technology to our own personal tastes and requirements, so why not finding out more on how to adapt it to the more challenging needs of our clients?

When things become more technologically complex, an OT should never act in isolation, and other professional perspectives and support should be actively sought from local specialist teams and charities. Collaboration with these teams can increase our existing knowledge, enrich our practice and make us better prepared to meet the needs of a wider population. Many OTs are already acknowledging that we are in a privileged position to use digital technologies to our advantage, and they continue to explore options appropriate to their client groups and needs.

As ‘access experts’, enabling people to pursue and succeed in their chosen occupations, OTs should aim to get involved in all aspects that affect an individual’s participation, including their daily use of digital technologies. We should familiarise ourselves with simple and cost-effective ways of adapting these technologies to meet users with a range of needs and disabilities, the same as we familiarise ourselves with other OT techniques and approaches to maximise our professional skills in other areas of practice. This should be part of our continuous professional development.

And finally, we can use Digital Technology in OT not only because it makes things easier, but because it can make things POSSIBLE (adapted from IBM training manual, 1991).

As always, questions, comments and personal experiences with digital technology in OT clinical practice will be very welcomed.

 

References and more Information:

http://www.aota.org/About-Occupational-Therapy/Professionals/RDP/assistive-technology.aspx (Accessed January 2015)

American Occupational Therapy Association. (2010). Specialized knowledge and skills in technology and environmental interventions for occupational therapy practice. American Journal of Occupational Therapy, 64, S44–S56. doi:10.5014/ajot.2010.64S44

Terrer-Perez, P (2013). ‘Digital Assistive Technology: A Core Skill for OTs Working with Children?’. OT News, January(2): 32.

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Digital Assistive Technology and Visual Supports for Autism: A quick guide to motivating and effective resources to support independence.

 

Visual Supports picture.jpgMost people with Autism already have an intense relationship with digital technologies. Digital Assistive Technology (DAT) is just a step further from the visual supports concept: it is fast, versatile and motivating to people with Autistic. More importantly, it has quickly developed a range of accessible options for users with autism to participate in a large range of activities (i.e. academic/educational, self-care, communication, choice-making, schedules, creative, sensory and self-regulating, etc.).

DAT consists of any electronic equipment or adaptive devices that enable a person with a disability to access a range of functional activities such as communication, play, academic work, leisure interests / games, etc. Some examples of DAT can include an adapted laptop, specialist mice and keyboards, switches, iPads and Tablets, mobile phones, iPods, etc.

The main interface with the technology is predominantly visual and tactile, which makes it attractive, predictable and simple to the person with autism. Additionally, most digital devices allow two-way interactions for the users and are not merely passive visual rewards. The special needs market is currently flooded with offers of software, hardware and applications (apps) for people with autism, to help with participation in a range of areas. There is also plenty of ‘anecdotal’ evidence from parents to support the use of devices for children with autism, although this should be treated with caution, as more rigorous research has not been carried out at this stage.

As DAT options continue to change, with new products and updates being launched every week, the following sections aim to summarise some of the most useful software and apps that have been developed so far and proven useful in assisting people with autism in the area of visual supports:

  1. Visual Supports Software

This is a web-based solution to create personalised boards, with many features such as speech output (in different languages) and access to good quality images through an  integrated Google image search, plus thousands of unique, custom symbols with SymbolStix© and the new PiCS© symbol system. The board can be shared between different users and devices, and there is an app version for iPads.

A free Windows application, Picto-selector is able to create boards and sheets, inserting the user’s own pictures or symbols or choosing from over 24,000 pictures and symbols in the programme. It saves as a PDF and copies can be printed as well.

Their Visuals Engine offers the possibility of creating quick social stories and charts. Resources can be created within the webpage’s templates and with access to Boardmaker symbols or any other personal images. There are many templates to choose from, such as choices, time, rules, schedules, personal stories, etc. It can be printed or saved as PDF to be shared.

Similar to Pogoboards, this is an easy-to-use online resource that allows users to create various customized learning materials and social stories. Resources created can be saved, shared and printed.

This programme is one of the first and most widely-known visual resource creator that also can double-up as a communication system. Their range of symbols has become familiar in many educational settings, due to their simplicity and quality. Their large online community has thousands of already-made resources, books, charts, schedules, etc. that can be readily used by subscribers. It is based on their own ‘symbol set’, Picture Communication Symbols™ (PCS), but other graphics or images can be added as well.

A ready-made board created with Boardmaker

Boardmaker

Similar to Boardmaker but with the popular ‘Widgit’ images is the symbol-based programme Communicate in Print: http://www.widgit.com/products/inprint/index.htm

  1. Visual Supports Apps

The following are a few useful applications (apps) available for Apple (iPhone, iPod and iPad) and Android devices to create social stories and other types of visual supports. Most of them have symbols/picture libraries, but can be modified to add the user’s own images and even familiar voices / sounds / music. Most visual supports created with these apps can be are editable, printable and can be shared among devices afterwards.

The following is not meant to be a comprehensive list, but a few useful apps that can assist setting up visual supports in a range of DAT devices (all for iPad, with some Android versions as well):

  • StoryMaker for Social Stories
  • Stories About Me
  • Stories2Learn
  • i Create… Social Skills Stories
  • All about me Story Book
  • My Life Skills Box
  • First Then Visual Schedule (Android version as well)
  • iPrompts (Android version as well)

With over a thousand apps now available to help individuals with special needs it has become increasingly difficult to find and choose the right special needs app. It is worth looking at websites that regularly review and update apps and software for people with Autism, but even these sites keep increasing in number and frequently updating their content. In some cases, it might be worth to trial the Free or ‘Lite’ version of the app first, before a decision is made to purchase it. Some trusted reviews can be found in the following sites:

OTHER RESOURCES and USEFUL WEBSITES:

NAS – National Autistic Society

The National Autistic Society has excellent and free handouts on visual supports and social stories with examples, reading materials and other ideas for resources.

http://www.autism.org.uk/living-with-autism/strategies-and-approaches/visual-supports.aspx

Do2Learn

www.do2learn.com
Do2Learn provides special learning resources for individuals with disabilities and professionals and caregivers around them. They freely offer many pages of FREE good quality visual resources, with templates and ideas to incorporate them in daily situations.

WIDGIT SYMBOLS

Most software packages that contain Widgit symbols can be found here: http://www.widgit.com/

MORE FREE RESOURCES:

Free downloadable databases and picture dictionaries that can be used as visual supports for a variety of situations:

 

 

7 STEPS THAT WILL HELP YOU DECIDE ON THE BEST DIGITAL ASSISTIVE TECHNOLOGY FOR YOUR CLIENTS

assistive technology

I feel passionate about digital assistive technology, and I don’t think it has to do with the fact that I work with younger clients (well, maybe a little). As an OT, for many years I have seen the different a well-chosen piece of equipment can do to assist a person access a meaningful daily activity. For me, digital assistive technology is just a step further from this concept: it is fast, versatile and motivating to a wide range of people from different backgrounds, interests and ages. More importantly, it has quickly developed a range of accessible options for people with disabilities and it can work excellently as a means to an end (i.e. environmental control).

Professionals from every field have rapidly acknowledged the value that technology offers to their clients; however, OTs frequently decide that they lack expertise or that it may be other profession’s remit to deal with these issues. Additionally, OTs already have knowledge of important underlying skills, such as how to improve positioning, arm and hand function, visual-perception, etc., all of which play an essential role when deciding the type of technology to prescribe.

At the end of the day, one Ipad-size does (NOT) fit all!

It can also feel daunting to dig deeper in this area, since there are currently so many choices and the technology changes fast, at times to attract further consumers but frequently to improve its functionality and resolve glitches.

So here is a quick guide to restore confidence on our skills and encourage the use of digital assistive technology in our day-to-day practice:

  1. Address Postural Needs: This should be the first thing to consider before further assessment is carried out. In most cases, the person will need to accurately use their hands or other body parts to access technology: your job is to make them as stable and comfortable as possible, so don’t hesitate to use appropriate chairs, work surfaces, footrests, cushions, angled desktops, wrist supports, etc.

Then comes deciding on a position for the system: this also needs to be stable and in the same place, as we don’t want to change the demands of the task every time for the user. Appropriate placing or fixed mounting of the equipment will maximise physical access to the system tried. Once a successful set up has been agreed, another job is to convince everyone not to alter it, to achieve consistency and ease of access in the long run. Use permanent markers and take pictures of the person using their system in the right set-up, then ensure this information is shared with all involved, including the client.

  1. Assess physical abilities and reliable movement patterns: as OTs, it is second nature to us to measure underlying capacities (i.e. muscle tone, range of movement, joint laxity, type of grasps, bilateral coordination, finger dexterity, etc.); but what we really need to know here are the effortless, consistent and reliable movements that will enable accurate access to a technology system. Look at the wider picture here: have a look at the ways in which the person moves and interacts with other motivating objects in a familiar situation. The hands are always the preferred (and often easier) option, but at times we may need to consider other body parts, if they are more reliable or require less effort from the user (i.e. head, knee, eyes, etc).
  1. Consider sensory needs: such as visual impairments, visual perception difficulties, auditory loss, additional sensory processing needs, etc. These will all change the way of accessing technology. Fortunately, many operating systems and websites currently offer different accessibility options targeted to sensory impaired users. Specialist software should only be considered after the ‘accessibility options’ from an operating system have been unsuccessful to facilitate access.
  1. Before meeting the user, find out first the type of communication and literacy level of the user: verbal, written, pictures, gestures/ Makaton, BSL, symbols, picture grids, etc.  Consult and involve an SLT if the main purpose of the equipment will be communicative. The level of literacy of the user may rule out options solely based on written language.
  1. Involve other people: It’s never a one-person job! Other professionals around the client will provide invaluable information for your assessments (e.g. teacher, SLT, psychologist, personal assistants/ carers, etc), and the family and the user’s views should be paramount. In the end, the user’s choices must always prevail; we are just facilitators offering the best matches to them.
  1. Function of equipment: in consultation with the user and the family/carers/education staff, determine what aims are to be achieved by introducing a new piece of equipment:  recording of work in class, communication, gaming, environmental control, etc. It is also in the interest of the student to limit the number of devices. Multi-purpose devices or compatibility between devices should always be encouraged first, where possible (i.e. tablet PC to record academic work, with adequate voice output for communication purposes).
  1. Training, Trials and inclusion in real life: It is essential to check what has been tried in the past already when choosing a new system to trial. The person’s natural environment is always preferable to carry out any assessments and trials in, to detect further difficulties that may prevent access to the system. If there is quite a high cost implication, try to get the company to do a short term loan or use their ‘returns’ policy if unsuitable after a trial.

Support is crucial after provision: ensure everybody is trained and has sufficient knowledge of the system (but don’t bombard them with too much information). Identify and agree with the user and support staff the times of the day when the equipment can be used to ensure full integration in their routines, rather than an extra chore that everybody forgets after a while.

Generally speaking, if a person appears to have a delay or a difficulty in activity participation or communication, technology should be introduced as early as possible in that person’s life. Most children, young people and adults already have access to technology round the clock as part of their school, work and leisure routines. Many older adults are already introducing it in their lives to ensure participation in meaningful activities such as talking to relatives on Skype, selecting a favourite large print book on their e-reader or reminding themselves of their medication using phone alarms.

It is an OT’s responsibility (in conjunction with other relevant professionals) to carry out a client-centred assessment of AT needs, to prescribe appropriate resources and initiate onward specialist referrals for all clients requiring AT to enhance their participation in relevant daily activities. An occupational therapist is a ‘core professional’ that has an essential contribution to this type of assessments, but further skill development may be required in this area, to match existing professional skills with the advantages of new and emerging technologies.

 

COACHING SKILLS: ARE THEY HAVING A ‘COME BACK’ IN OCCUPATIONAL THERAPY?

                                      Coach           

While attending an interesting training day at Guy’s Hospital from Sylvia Rogers (ASD expert and best practice advocator), she drew our attention to the fact that occupational performance ‘coaching’ and other related concepts seem to be appearing again in recent OT literature generated by our colleagues.

Afterwards, I decided to persuade my team into having a whole journal club and discussion around it so that we could explore how this really works in OT clinical practice. After digging up a few recent articles (see some Refs at the end), it still looked like a reasonable idea. It brings together key longstanding OT concepts such as client/family centeredness and occupation-based practice, as well as the idea of enabling participation in the person’s natural environment.

This really got me thinking: after doing our occupation-based assessments and client-centred goal setting; are we still making our clients the passive recipients of our interventions, based on the assumption that we are professionally trained and should model the right way of doing things, or that they expect us to come up with the solutions to their problems anyway? Are there other people out there alone in a therapy clinic treating a child that does not want to be there and a mother that feels that it is your job to change her child’s difficulties into achievements?

There has to be a better way of getting families (or teachers or a wider constellation of people around our clients) invested in our interventions. We should not take whole responsibility for the success of our interventions, and, more importantly, we could even save some valuable therapy time in the long run!

Although there seems to be several approaches to coaching (i.e. solution-focused, occupational performance coaching, problem-solving interventions, etc.), they all seem to share a number of (not steps, as they do not follow a sequence) common features:

–          Joint planning and collaborative relationships are essential to make this approach work.

–          Observations of the new strategy being implemented by the parent / client/ carer.

–          Real Life practice of the ‘strategy’.

–          Reflection to gain insights into the strategies attempted.

–          Feedback from the professional related to further development of new strategies and resources.

My team also felt that there are many similarities to the CO-OP approach for children with DCD (http://www.ot.utoronto.ca/coop/about.htm ), and there is also good evidence behind this method.

Personally, I see a few gaps in the application of this model of service delivery:

–          It is heavily dependent on Language, which rules out families with poor verbal/literacy/understanding skills and possibly from other cultures.

–          Requires a good insight from the user, so it may not be appropriate for parents/clients who have difficulties to recognise their own problems and have an overly positive vision of the goals they would like to achieve.

–          The OT does not provide intervention ideas based on his/her own expertise. This can be quite limiting and potentially de-skilling for the professional: can we not give parents a little background on their child’s condition or existing good practice, to help them make better informed decisions later on when deciding on their own strategies? Can we not at least make some suggestions or model successful tried and tested methods (i.e. backward chaining, visual supports, sensory calming techniques or equipment, etc.)?

In the end, we decided that it may not be applicable to everyone, but the whole idea of ‘coaching’ to create an optimal environment that improves our client’s chances for motivation and change continues to appeal to OT practitioners and supports our core beliefs.

At this stage, we are keen to find out more. Studies on OT interventions are still in their infancy (small studies and case reports), but evidence is apparently robust in other disciplines such as education, business and psychology. Let’s not forget that ‘Life coaching’ has been around for a very long time and its popularity is not fading.

Are OTs to become the ‘new’ experts in occupational performance coaching?

What are your thoughts on this topic? Let us know if you are already using this approach in your practice.

Refs.

Aust Occup Ther J. 2009 Feb;56(1):16-23. Coaching parents to enable children’s participation: an approach for working with parents and their children. Graham F, Rodger S, Ziviani J.

Phys Occup Ther Pediatr. 2013 Apr 24. Solution-Focused Coaching in Pediatric Rehabilitation: An Integrated Model for Practice. Baldwin P, King G, Evans J, McDougall S, Tucker MA, Servais M.

Phys Occup Ther Pediatr. 2013 May;33(2):253-63. Coaching mothers of children with autism: a qualitative study for occupational therapy practice. Foster L, Dunn W, Lawson LM.

Useful OT website with more information on Occupational Performance Coaching: http://www.occupationaltherapycoaching.com/