Where to start?

After collecting all the background information from an individual's case file (if one exists) most OTs will start with a standard OT interview/assessment, and some will use a structured tool such as the COPM to help identify goals. A 24 hour activity log can be a helpful starting point if technology needs are high - for example, an individual with highly limited mobility may be asked to list activities they do, and current technologies in place, something like this:

Activity	Time Spent on This	Degree of Independence	Aids Used
dressing	75 minutes/day	need help with fasteners	long reacher bedrail for balance
reading	2 - 3 hours/day	independent	book rest; magnifier

Using a structured approach to identify activities that the client is struggling with or would be able to perform more effectively with the aid of AT starts us on the road to understanding the Activity portion of the HAAT. The interview should explore:

• short and long term goals - what roles, occupations, and activities are important to the individual?
• past experience with technology
• willingness to consider technology as a solution
• resources: personal stamina; temperment; financial resources; the "soft technologies" that are available such as family members, teaching assistants, personal assistants, co-workers, tech savvy neighbours, etc.
• what areas of functioning are difficult? This will help identify areas needing detailed assessment

The interview is a key part of the AT assessment, because it helps determine the client's comfort level with various levels of technology, how important it is for him/her to perform various tasks identified independently, how AT will "fit" into their lifestyle, and thus, how likely they are to really use it in the long run. If there will a learning curve and certain frustrations related to a certain type of technology, is the client likely to stick with it? Is it likely to work in various environments where it would be needed? Is it even feasible given the financial situation?

To select assistive devices to optimize the PEO fit, it is easy to start with a list of what the person is not able to do and try to find a piece of technology that accommodates for that deficit. This can lead to a prescription that makes sense on paper as it appears to compensate for what the person can’t do, but when all the pieces are combined for the individual in context and the occupations themselves are considered, it may make little sense.

Considering all the requirements for successful completion of an occupation is also important. Writing, for example, is the culmination of many neurological and cognitive activities, far exceeding a simple fine motor issue. If a client is unable to write effectively and efficiently in the typical pen-to-paper way, it may be a function of working memory, processing speed, attention, and organizational issues. As such, an assessment of fine motor skills will not give you enough information to determine if AT is warranted.

 

Detailed Evaluation for the Human-Technology Interface

With any electronic devices, there are a variety of ways that humans can input information, or communicate with the equipment. This is called the human-technology interface. When you use a computer, for example, the keyboard and mouse are tools for telling the computer what letters or functions you want to choose. With an augmentative communication device, there has to be a means for the user to tell the device what words or sentences to say on their behalf. We have many options for these interfaces, which is why you would have done a careful assessment of the individual skills and characteristics of the client to know what options to consider. For the computer, we are going to consider a variety of keyboard and mouse-type interfaces. When we look at switches, you will see a number of other human-technology interfaces suitable for individuals with very limited physical capacity.

Motor Skills

Imagine a large picture communication board. What motor skills would an individual need to be able to use it effectively if it were positioned on a table or lap tray in front of him/her?

Depending on the size of the images, they would need:

• to have enough upper limb strength to keep at least one arm elevated and in motion for several minutes at a time
• adequate motor control to be able to precisely select a single picture at a time
• enough reach to cover all parts of the board

Similar considerations exist for most different types of devices, such as keyboards, mice, phone or ABM dial pads, etc. Strength, ROM and motor control are important aspects of the human-technology interface. If these are a concern, your assessment should include:

• assessment of targeting (being able to hit targets of varying size) speed and accuracy
• reaction time (how long does it take before the motor response starts?)
• fatigue (does performance fall off after a period of activity?)
• ability to reliably hit targets in different planes (could mounting a switch or a keyboard at a certain angle or in a different position improve performance?)

The assessment should include a screening of not only upper body strength, but also head control and movement, foot and leg control, and vocal ability. Remember, human-technology interface options include switches that can be activated with any part of the body, the eye and the voice. For voice input to be a possibility, there must be adequate voice support (loud enough) and consistency of vocal output (i.e. even if words are hard to understand, is it the same every time?).

Cognition

In many situations, you will be able to obtain information on cognitive level through the interview, review of school or health records, or through cognitive screening. What would be key concerns with respect to technology use? It would be important to consider:

• ability to understand and use various software and hardware programs
• reading level in terms of computer or augmentative & alternative communication (AAC) devices
• memory skills
• attention span
• does the client have a basic understanding of cause and effect (i.e. actions taken result in a device doing something)

Overall, it is said that there is a balancing act between the physical and cognitive load of an activity. Consider Morse code. This system, developed during the first world war, uses a series of dots and dashes to form letters. An individual who knows it well can communicate perfectly in words, even with virtually no motor skills. They can use it via a simple one or two function switch operated by a finger, a head or knee-operated switch, eyeblink, or even the clicking of a tongue (although the latter would likely need a human to transfer it into letters and words!) to communicate via a computer or other program. So the system has a very low physical load. The cognitive load is very high, however. The user must be able to remember the code for every letter, or be able to find it quickly on a chart; they must also be able to keep track mentally of the spelling of words, and how the sentence is emerging. Clearly, it is important to keep in mind the physical and cognitive load of various technology solutions, and how well they fit with the characteristics of the user.

Sensory Functioning

Vision and hearing are key issues to consider, partly due to the importance they hold with respect to conducting a valid assessment. A large portion of clients with multiple physical disabilities also have a visual impairment - meaning that if you are asking them to hit certain targets, they may miss the mark not due to cognitive or physical impairment, but because they simply cannot see well enough to hit the required spot. Hearing is also a concern in assessment for many clients, and clearly can compromise an assessment.

Beyond its importance in assessment, sensory function is key to eventual success in using assistive technology. If a client is visually impaired or blind, is there adequate tactile sensation to locate and activate an input device? Will auditory feedback be effective? If compensation for visual or hearing loss is necessary, a wide range of augmentative devices and computer adaptations are available. These will become part of the AT recommendation and device assessment.

Psycho-Emotional Functioning

A major factor in adoption of technology is the attitudes and emotional status of the client. You can assess this partially through the interview, through review of any assessments conducted by other professionals, and also through observation of the client in task performance. Key elements to consider include:

• task focus - is this a person with good task completion skills who is likely to tolerate a tedious learning process?
• frustration tolerance - any advanced technology is sure to have glitches. Will the client tolerate problems?
• judgment - some technologies, such as power chairs, scooters, environmental controls and computers require good judgment skills, and the ability to use the device safely.
• motivation - if the client has low interest in an activity, or is amotivational in general, it may be that he or she will be unlikely to try something new, persist through a long period of training, or to work through the inevitable technology glitches. Be careful, though - for an individual who has been experiencing occupational deprivation due to an inability to control the environment, communicate, or make independent choices, the use of AT may be just the thing to enable and generate enthusiasm for living.

Consider using the technology itself as part of the assessment where it will add information on best performance. Rather than making recommendations purely on the basis of assessments of individual performance components, also assess the overall functional performance itself, with and without the assistive technology. Other standardized assessments of performance such as the Test of Written Spelling could be used to compare a student’s ability to generate correctly spelled words with and without word prediction or dictation software. By integrating the technology itself into the assessment, you can help to engage the client in the becoming aspect of occupational therapy and collaborate to develop strategies that would support participation in the client’s occupational narrative of the future, eliciting client buy-in and building therapeutic rapport.