An illustration of a boy using a head switch connected to a mounting arm

Switch access: the first way forward in AAC assistive technology

THE JOURNAL OF COMMUNICATION MATTERS / ISAAC (UK)

Esther Dakin-Poole, Head of Education & Development, Smile Smart Technology

Talk given at Communication Matters Conference, Leeds University, Sept. 2017

Abstract

Switch access today is the most common entry point to AAC devices and autonomous control in a wide range of current assistive technology products. The argument is made that methodological approaches proposed in the past by researchers promoting joystick use in powerchairs over switch access should be rejected as an outmoded concept for those with complex needs, due to the multidisciplinary demands and integrated nature of contemporary assistive technology.

Introduction

It is strongly believed that we are currently reaching an important turning-point in the both AAC and wider Assistive Technology practice (Peters, 2017) (Sik-Lányi Et Al., 2015; Kirkpatrick, 2016) and that we must grasp the opportunity to work more closely with all stakeholders and respect all our colleagues equally regardless of whether they hold a syringe, pencil, switch or spanner as we move forward into the age of the Fourth Industrial Revolution (4IR).

Two of the most basic principles of every creature on this planet are to be able to communicate and move.  So technologically speaking the world of disability has evidently made enormous progress in many different ways to enable humans to communicate using contemporary engineering and electronics.  The world of movement has also been refined and enhanced through the same electronic advancement process and through use of superior materials, but only up to a point. Many of the advances in movement have been in controls programming, however the method of inputting those controls has hardly varied over the last 10-15 years.

For those able to operate a joystick successfully there are various sizes available with varying degrees of sensitivity and at the point of assessment your competency outcomes are binary: you succeed or fail when you are tested. If you fail that competency test for safety reasons, you become a special case.  At this juncture the process has historically been at best confusing and at worst arbitrary. If switches are the chosen option, key consultations with the case physiotherapist or occupational therapist are fundamental to ensuring that the seating is optimised to enable switch operation to be consistent and accurate. The established route is to consider switching as a secondary alternative to joystick use and dependent specifications are prescribed from scale, positioning and ease of operation. This process can take weeks or even months in the UK, dependent upon whom is carrying out the assessment, what resources are available to fabricate suitable switch mounts and the frequency of clinic dates for reviews and alterations to equipment or repositioning. It is felt that greater interdisciplinary assessment consistency and speed must be brought to current systems.

How is communication switching allied to movement?

Whilst there are various aspects of control switching set-ups that are common to both the operations of a communication device and a mobility device, the risks involved in switching for ‘driving’ is fundamentally different. If a switch is used on a communication device the degree of accuracy in operation is less problematic than for driving. Whilst a random misguided operation of a switch on a device may cause anger and/or frustration for the user, when this occurs during driving pain or damage can occur very swiftly to the individual or any people and surrounding objects. Whilst both disciplines use fundamentally the same input hardware, their potential operation and outcome can be far apart. If switching is optimized, the fatigue and frustration normally experienced by the users can be much reduced – and through using safe motivational teaching tools and empathetic methods, accuracy of all switch use can be greatly improved.

At Smile we use certain essential principles in our methodology that we formally call ‘the Dakin method’ which we really call ‘sneaky therapy’. This is a gentle progressive teaching method that moves away from the inflexibilities of historical practice. Our areas of consideration are: Ability, Access, Advancement, Age, Angle, Autonomy.

Ability – is a mixture of understanding an individual’s potential capacity and our belief in them. Our hardest task is to assess a child or adult with little feedback upon first meeting. We firstly read their eyes and their body language especially where they are non-vocal. We are trying to unravel a detective story and look for clues. Parents, teachers and carers are all vital in helping to provide clues to understanding personal motivations and fears and must be listened to.

Access – Which input deviceto use? Joysticks are not suitable for everyone, and multiple switching is equally problematic given the layout and space required. A combination of two switches provide many options from scanning to direct steering – you cannot pull a switch sideways as happens with joysticks. Technicians and support staff are important to communicate with to better understand common risk factors in transport, private space and regular technical damage before this decision is made. Many are able to use joysticks with ease. For those who are borderline we would now strongly encourage focus upon switch access teaching. Frequent use of switching, we find improves switch accuracy rates and we would welcome additional research in this field.

Sneaky therapy begins with single switch and timed access, we can stage progress through to a press and hold activation, and for some on to free driving using our in-house tools, starting with the Drivedeck at assessment level. Turning sensitivity settings down incrementally until proficiency enables the user to maintain a constant ‘move-to-press’ pressure – which is so helpful in the later progression of scanning. Incentivization given by the physical sensation of autonomous movement – the visceral cognizance, the perception of the user’s body moving safely through a space controlled with their own repeated action is an extremely powerful motivating force. It is predominantly through the use of switches rather than joysticks that many AAC users will be most immediately integrated into the use of web-based technologies that exist today, therefore we argue for stronger emphasis upon switch access, particularly where safe autonomous driving is not a realistic development option. In view of innovation through 4IR, where mechanical, electronic and biomechanical engineering merge progressively closer together, we are witnessing a greater integration of technologies and skills. We must take care not to needlessly specify overly complex technologies that exhaust the energy of users at the expense of learning essential skills such as switch training.

One example of transitioning to new forms of autonomous situations using simple switch access and in this instance Smile tools is a young man called George. George has Downs Syndrome, he suffered a stroke and became blind. Previously he had independently enjoyed the sensory room as a space to explore switches and play games on the computer. After his stroke visits to the main sensory space reduced to once a week and often sat in dire boredom in the TV room as he had become unable to move himself around the building or access the computer. To help overcome his new world without his sight, switches and Smile line following tools were provided to him and the computer was moved into his own room. This enabled him to move semi-autonomously when he wanted to visit his friends in the TV room and then safely return to his own room to game or rest, even without his sight or the ability to walk. George’s enjoyment of personal independence both physically and mentally was returned to him. The understanding of switches allowed him to adapt to his new sensory world.

Age – We would like to see all children start their access to autonomous independence, both physical and communicatory at the earliest possible age. Indeed, we believe that this should be happening at the same age that children without disabilities would be beginning their crawling and walking development – to allow them to progress as naturally as possible with the assistance of their relevant assistive technology. To leave a child until they are 8 or older we believe is to waste vital years of integrated development with the right technology. This is a contentious point, but we frequently witness the clear benefit of early intervention and would encourage further research in this area.

Many problems we face concerning age is growth related, particularly in teenage boys for whom delays can mean products quickly become unfit for purpose due to body size and strength. The problem of not looking forward is illustrated by the case of Hercules. His fast growth and increased strength in teenage years should have been given consideration by therapists at assessment and would have benefitted from greater dialogue with other team members. Due to a combination of the traditionally slow prescribing processes mentioned above and his dramatic increase in size through puberty onset, which increased his strength and tonal fluctuations, by the product delivery date the prescribed AT and teaching methods had become obsolete. Nearly two years of productive development was lost. 

Advancement – How to optimize potential by looking forward to where technology will be allowing an individual to be in the future. We are currently at a new frontier of electronic assistive technology access. We wish to see individuals optimize the full potential access that their brains are capable of – not limited by physical conditions or historic technology. Advances in technology provide us with access to previously unthinkable abilities such as 3D printing and gaming.  One example of a mother’s vision involved her eight-year-old girl called Tilly. Tilly’s mother had been told by a therapist that her daughter would only ever be able to use eyegaze at the very most and never be capable of anything more physically or intellectually complex. Tilly’s mother challenged this and made the point that her daughter had only recently learnt the use of eyegaze and communicated in three languages. At her first attempt on the Drivedeck assessment device, despite never having any previous switch experience Tilly instantly understood the correlation of switch and movement and now enjoys a strong level of physical and communicatory autonomy at home and school.  Her mother had a strong perception of her abilities and looked ahead for her daughter who will now have far greater access to education and autonomy in future.

Angle – Comfort and empathy are key to successful access. We must provide switch users the most immediate and comfortable angle of positioning in switching to enable immediate success. Once new users have realized what they are able to accomplish with the switch, one can then instigate the key physical element of sneaky therapy. Switches can be stealthily moved over time to achieve the therapist’s long-term goal for position and activation, as muscle and memory gently allow. Maintaining the momentum and progress gained at any level of success must be kept at all cost, and great care must be taken to consider comfort, as unless the repeat process is painless success will be slow, limited or absent.

AUTONOMY! –  The end goal…the motivation behind the entire process. Giving any individual the ability to move without the pressure of navigating is a tremendous bonus. There is no pressure. It is pure pleasure. Autonomy through switching, where joystick use is too challenging, is what we see as the key motivation needed to move on to switching in AAC access and the foundation of our teaching. Using these keystones we build our approach to facilitate the optimum progress of those we work with. This methodology integrates the consideration for the work of our colleagues even if we are unable to speak to them directly. We encourage greater direct communication between all advisors and stakeholders in support teams, with the focal point being upon the holistic provision of streamlined services to speed up all provision of assistive technology devices and integration of therapies. We strongly welcome joint assessment meetings with all stakeholders, as on the rare occasions that this occurs outcomes are greater and faster than the norm.

The historical divide between health and education is we believe outdated {Dakin, 2017, The drive for a holistic approach to mounting communication equipment.}(Dakin, 2017). Technology accessible on the outside of our bodies is now facilitating what was previously only accessible from the inside. The demand for better, smaller, less intrusive design and innovation is blurring the functions of specialists and placing ever increasing demands upon therapists and care teams. In order for practitioners to work more effectively for those we advise, we each must understand and respect more the impact of each other’s work and acknowledge that due to the new interconnected nature of technology, education, communication, driving and health support we must work more closely together at every stage.

We believe that in AAC and the allied professions of this field our access point to technology must also evolve. Eyegaze and similar ocular dependent access is an important and exciting entry point that we look forward to researching further. Given the cross-over between driving, scanning, gaming and general computer and tablet access, which are all accessible through switches, we feel very strongly that double switch teaching must be encouraged wherever possible. Our approach exists to enable users to make maximum use of switches, whether connected to a communication or mobility device, this encourages users to be proactive not reactive. If one switch can be operated you can communicate and move, if you can operate two switches you can gain access to today’s online world and increase opportunities in achieving future education, employment and social goals.

BIBLIOGRAPHY

DAKIN-POOLE, E. The drive for a holistic approach to mounting communication equipment. The Journal of Communication Matters/ ISAAC (UK), v. 31, n. April, p. 31-33,  2017.  

KIRKPATRICK, K. Existing technologies can assist the disabled. Communications of the ACM, v. 59, n. 4, p. 16-18,  2016. ISSN 0001-0782. 

PETERS, M. A. Technological unemployment: Educating for the fourth industrial revolution. Educational Philosophy And Theory, v. 49, n. 1, p. pp1-6,  2017. ISSN 0013-1857. 

SIK-LÁNYI ET AL., C. Assistive Technology : Building Bridges.  Fairfax: IOS Press, 2015.  ISBN 9781614995661.