Cognitive Accessibility User Research

Cognitive Accessibility User Research describes the challenges of using web technologies for people with learning disabilities or cognitive disabilities. The research describes challenges in the areas of attention, executive function, knowledge, language, literacy, memory, perception, and reasoning. It is organized by user groups of the following disabilities: Aging-Related Cognitive Decline, Aphasia, Attention Deficit Hyperactivity Disorder, Autism, Intellectual Disability, Dyscalculia, Dyslexia, and Non-Verbal. Additional user groups may be added to future versions. This document provides a basis for subsequent work to identify gaps in current technologies, suggest strategies to improve accessibility for these user groups, and develop guidance and techniques for web authors.

Summary of User Groups and Cognitive Function

Different people with cognitive disabilities may have problems in the following areas:

Memory - Including: Working Memory, Short-Term Memory, Long-Term Memory, Visual Memory, Visuo-spatial Memory, Auditory Memory (memory for sound patterns and others).
Executive Functions - Including: Emotional Control and Self-Monitoring; Planning/Organization and Execution; and Judgment.
Reasoning - Including: Fluid Reasoning (logical reasoning), Mathematical Intelligence, Seriation, Crystallized Intelligence, and Abstraction.
Attention - Including: Selective Attention, and Sustained Attention.
Language - Including: Speech Perception, Auditory Discrimination, Naming Skills, and Morphosyntax.
Understanding Figurative Language - Including: similes, personification, oxymorons, idioms, and puns.
Literacy - Depends upon functions including: Speech Perception, Visual Perception, Phoneme Processing, and Cross-Modal Association (association of sign and concept).
Other Perception - Including: Motor Perception, Psychomotor Perception.
Knowledge - Including: Cultural Knowledge, Jargon (subject matter); Web Jargon and Technology; Metaphors and Idioms; Symbols Knowledge (such as icons); and Mathematical Knowledge.
Behavioral - Including: Understanding Social Cues.

For more information, please see section 5.

It is important to note that people may have limitations in one area and not in other areas. For example, a person with dyslexia may have above-average reasoning, but impaired visual memory and literacy skills. A person with Intellectual Disability may have an above-average visual memory, but impaired judgment.

Cognitive Function Table and Tags
Cognitive Function Category	Cognitive Function Subcategories and Tags	Dyslexia	Aphasia	Non-Verbal	Intellectual Disability	Autism	Dyscalculia	Aging-Related Cognitive Decline	Attention Deficit Disorder (ADD/ ADHD)
Memory	Duration Based Working Memory Short-Term Memory -typically lasts seconds Long-Term Memory - (includes recall and writing - the ability to learn, such as learn a new symbol and use it the next day.) Context Based Episodic Memory(autobiographical – time, self) Semantic Memory (factual) Visual Memory Visuo-Spatial Memory Auditory Memory: memory for sound patterns (um) Procedural Memory Musical Memory Prospective Memory - remembering to do things in the future, such as keep appointments, return a book to the library, or pay bills on time Emotional Memory Awareness based Implicit memory: (non-declarative memory) Explicit Memory: (declarative memory, intentional use of memory) Also memories can be stored and recalled as Associative Memory (MA) Meaningful Memory (MM) Free-recall Memory(M6)	May have impaired: Short-Term Memory Visual Memory Visuo-spatial Memory Auditory Memory Procedural Memory Prospective Memory	Receptive and Expressive Aphasia may result in impaired short term memory which can impact on re-learning language as can the impairment of auditory memory for relearning correct articulation and visual memory that affects reading and writing. Visuo-spatial Memory maybe an issue with the inability to remember how to get to places and recall locations, not helped if procedural memory is also involved where the order of doing things is affected. This is usually automatic but actions may have to be relearnt and there can be involvement of prospective memory that involves being aware of when certain activities have to be performed.	Cognitive impairments may result in impaired short term memory which can impact on learning how to use any symbolic representations of speech such as pictograms and other photographic symbols. This may result in a very reduced number of symbols being used on a daily basis. Lack of Auditory memory affects the ability to gain skills in phonemic awareness that aids literacy skills. Difficulties with visuo-spatial memory impact on the speed withwhich symbols may be found on a communication board or located on a screen and with physical difficulties this can further slow communication. Procedural memory difficulties result in poor automaticity in terms of Language Acquisition through Motor Planning (LAMP) which is one of the ways individuals can speed their AAC output.	Impaired auditory (verbal) short-term memory, and explicit long-term memory. However, visuospatial short-term memory, associative learning, and implicit long-term memory functions are preserved. Short-term auditory memory, which can affect writing to long-term auditory memory. Visual memory is often far-stronger. Difficulty remembering information.	There may be problems with memory, and integration of Episodic Memory (past experience) with present action.	Memory may be affected: Mainly Visuo-Spatial and Procedural Memory for layout, schedules, or sequences; and Prospective Memory for things such as financial planning.	Affected in dementia: Primarily new memories and working memory. Long-term memory becomes affected as dementia progresses. Age related cognitive decline may result in slight forgetfulness.	Working memory may be affected.
Executive Functions	Executive Functions Emotional Control and Self-Monitoring Shift (also called task flexibility) Initiation Planning/Organization and Execution Judgment	Sometimes affected: Planning/Organization	Those with Aphasia may have executive-functional difficulties especially if emotional lability is an issue. Cognitive impairment can affect cause and effect; and therefore planning and organization; as well as execution.		Problems with executive function, including: Difficulty with organizing and planning; difficulty working within time limits; sequences; emotional control and self monitoring; and judgment.	Sometimes affected: problem-solving; time management; planning and organization; emotional control and self monitoring; and inappropriate speech or behavior. Shift can be strongly affected.	Sometimes affected when involving numbers or time such as getting the right bus/train at the right time and on the correct platform.	All Executive Functions are affected in dementia. Sometimes Executive Function is affected in age-related cognitive decline, such as Shift and judgment (less often).	Executive function may be affected.
Reasoning	Fluid Reasoning (logical reasoning). Mathematical Intelligence Seriation - reasoning via seriation including organization. Conservation and Classification Behavioral -(or cognitive) component involving memory, such as long-term autobiographical memory. Crystallized Intelligence (sometimes called comprehension- knowledge) is the ability to use skills, knowledge, and experience. Abstraction	Typically not affected	Where intellectual capacity is affected there may be issues with reasoning, learning and thus remembering plus abstraction.	Where intellectual capacity is affected there may be issues with reasoning, learning and thus remembering plus abstraction.	Typically affected. Slow speed of information processing, such as a 'penny dropping' delay between hearing or reading something, and understanding and responding to it. Difficulty with Seriation, such as sequencing of events; strings of numbers and letters; time.	Typically affected: Behavioral intelligence, and understanding or relating to feelings; Interested in people, but not know how to talk, play, or relate to them; Difficulty dealing with change. Mathematical intelligence is also often affected.	Typically affected: Mathematical Intelligence; Seriation (such as estimating how much food to buy); and Abstraction.	Often affected in dementia including Behavioral. Crystallized Intelligence may be the strongest form of reasoning. Age-related cognitive decline can also lightly affect problem solving and reasoning.	Typically not affected other than planning, time estimates, and short-term recall, which is part of executive function.
Attention	Selective Attention -the ability to attend to some stimuli while disregarding others that are irrelevant to the task at hand. Divided Attention Sustained Attention	Selective Attention may be affected.	Shortened-attention span can occur with Aphasia.	Shortened attention span can occur alongside distractability when other cognitive impairments are present.	Difficulties with sustained attention.	Typically affected.		Affected in dementia.	Affected
Language	Speech Perception Speech Literacy See below for more details.		Aphasia can cause difficulties with word finding, the meanings of words and sentences, grammar and comprehension affecting the ability to communicate.	Young AAC users may have difficulty developing good sentence construction for written language in particular if reading skills are poor		Typically affected.
Speech Perception	Speech Perception depends upon: Auditory Discrimination (Note: not loss of hearing, butidentification and differentiation of sounds, also called general-sound discrimination (u3), Temporal Tracking (uk) Listening Ability (ls) Naming Skills (n) MorphosyntaxThe system of the internal structure of words (morphology) and the way in which words are put together to form phrases and sentences (syntax). Note: There is also related memory, such as working memory, auditory memory - see above. There is also knowledge required (see below), such as: Grammar Metaphors Lexical	Often affected: Auditory Discrimination Temporal tracking Naming skills Morphosyntax related memory	Individuals may have difficulties coping with the sounds that make up speech being unable to interpret their meaning which affects understanding and speech output.	Cognitive impairments can affect speech perception	Problems with morphosyntax. Problems with short-term auditory memory, affecting writing to long term auditory memory weaker-expressive language, and grammatical skills overall delayed language and speech development			Affected in dementia and, to a much-lesser degree, by age-related cognitive decline (temporal tracking).
Understanding Figural Language	Understanding figural language, such as: a simile, onomatopoeia, personification, an oxymoron, a paradox, an allusion, an idiom, and a pun. This is the ability to understand figural language, and does not include knowledge of metaphors.	Not affected	Idioms, metaphors, similes and other representations of language that contain abstract notions can cause issues for those with aphasia.	Idioms, metaphors, similes and other representations of language that contain abstract notions can cause issues for AAC users				Sometimes affected by dementia.
Literacy	Depends upon Speech Perception and visual perception. Also depends upon: Phoneme Processing phonetic coding (PC) Cross-Modal Association (association of sign and concept)	Affected	Aquired dyslexia can be an issue with individuals having to relearn how to read, sound out words and remember how to spell.	Aquired dyslexia can be an issue with individuals having to relearn how to read, sound out words and remember how to spell.	Problems with speech perceptions as above, spelling and grammar. Poor auditory-processing skills.	Typically affected.		Phoneme Processing and Cross-Modal Association are affected in dementia.
Visual Perception (visual recognition)	The visual system automatically groups elements into patterns: Proximity, Similarity, Closure, Symmetry, Common Fate (i.e. common motion), and Continuity. (Gestalt psychology) Functions include: Object Recognition Face Recognition (seems to be a different process from object recognition [Face and object recognition (Alex Huk. (1999) "Object and Face Recognition: Lecture Notes." pp. 5] Visual-Pattern Recognition	All can be affected. May also have visual stress.	Not recognising letters and words impact on reading and even object recognition can be affected.	Not recognising letters and words impact on reading and even object recognition can be affected	Strong visual memory but possible visual-processing difficulties May have visual stress	Visual comprehension is often affected.	Face Recognition, Object Recognition, and Visual-Pattern Recognition	Can be affected in dementia.	Diminished visual processing speeds
Other Perception	Auditory Perception (see Speech Perception above for further classifications), Motor Perception Tactile Perception Smell Perception Psychomotor Perception Kinesthetic Perception (body position, weight, or movement) Olfactory Perception and Sensory Perception	Auditory Perception affected Psychomotor may be affected	Auditory perceptual difficulties affect the relearning of speech and recognition of sounds and words impacting on understanding.	Auditory perceptual difficulties can affect phonemic awareness and any possible speech output	Psychomotor Perception seems affected. Difficulty with finding the way to places or navigating sensitivity to noise and visual stimuli. Impaired ability to screen out background noise / movement. Sensations of mental overload Tendency to "switch off".	Have unusual reactions to sensory-, olfactory-, smell-, tactile-, and auditory-perception sensory integration sensitivity to physical contact sensitivity to loud noises	Psychomotor Perception spatial orientation	Affected in dementia and, to a lesser degree, by age-related cognitive decline (such as Psychomotor Perception -Spatial/Temporal Understanding)	Developmental coordination disorder / motor clumsiness.
Knowledge	Types of knowledge that might be required for use of the Web include: Cultural Knowledge base Language Knowledge including: Lexical (UL) Jargon (subject matter) Web Jargon and technology Web and Technology Usages and Risks Metaphors and idioms Symbols Knowledge (such as icons) Mathematical Knowledge Mechanical Knowledge (MK) Knowledge of behaviors Design-Metaphor Knowledge Design-Functions Knowledge	Typically not affected.	Aphasia does not necessarily impact on intelligence but knowledge will be trapped within the brain if the individual cannot express their thoughts.	An AAC user does not necessarily have intellectual difficulties but knowledge can be trapped within the brain if the individual cannot express their thoughts.	Affected	Partial Knowledge of Behaviors	Mathematical Knowledge And Mechanical Knowledge are affected.	Affected in acquisition of new knowledge. Affected strongly in dementia
Behavioral	Behavioral Abstractions and social – Norms etc Social Cues other Behavioral	Slightly affected: Norms and Social Cues	Behaviour can be affected by lability where there can be unnatural emotions including depression. Tiredness can impact on the ability to cope with day to day activities.	Behaviour can be affected by the inability to communicate with considerable frustration occurring at times. Individuals may also become depressed and irritable, however these individuals can also show amazing resilience and understanding when issues arise.	Affected	Strongly affected (primary symptom)	Not affected	Affected in dementia
Consciousness	Delusions, Hallucinations	Typically not affected.	Consciousness in those who have deep Aphasia with no communication can be difficult to assess.	Consciousness in those who have no communication skillscan be difficult to assess			Not affected	Affected in dementia, such as delusions, and, to a lesser degree, by age-related cognitive decline, such as irritation and withdrawal.

Notes on the Cognitive Function Table:

Terms that will be used for tags are italicized and capitalized. Alternative terms are in brackets. Alternative terms will not be used as tags.
Discussions on the different functions can be found in section 4 below.
Speed: Processing speed affects all functions above. A related concept is fluency.

Research on User Groups

This section describes the state of the art in classification of cognitive function.

User group research modules follow. This is Phase 1. The group hopes to add more groups such as effects of Post-Traumatic Stress Disorder (PTSD) on cognitive function.

Dyslexia

Dyslexia is a syndrome best known for its effect on the development of literacy and language-related skills. There are a number of different definitions and descriptions of dyslexia. The syndrome of dyslexia is now widely recognized as being a specific learning disability of neurological origin. It does not imply low intelligence or poor educational potential. It is independent of race and social background.

Cognitive Functions

This section is a technical reference. Jump to the next section on #Symptoms for more practical information.

Overview: Mainstream credible research in behavioral neurology agrees that dyslexia is a consequence of an altered neural substrate in the various regions of the brain responsible for the reading process. fMRI scans [[Friston-1]], [[Talairach-1]] have shown different subgroups of dyslexia exhibit under-activity in areas such as:

V5/MT (BA Area 19) - resulting in visual discriminatory problems [[Eden-1]], [[Henderson-1]], possibly disturbing magnocellular function [[Stein-1]];
auditory cortex (BA areas 41 and 42) - resulting in low auditory-discrimination skills [[Tallal-1]];
superior-temporal gyrus (BA Area 22) Wernike's area and striate cortex or V1 (Area 17) - resulting in a phoneme processing problem [[Shaywitz-1]], ([[Black-1]], pages 331–376), [[Geschwind-1]], and pattern recognition;
the angular gyrus (Area 39) in the inferior parietal lobule - causing poor cross-modal associations ([[Black-1]], pages 331–376), [[Benson-1]], [[Dejerine-1]], ( [[Friedman-1]], pages 37–62).

Other studies [[Cao-1]] using PET have shown less activation than the controls in left-inferior frontal gyrus (BA areas 45, 44, 47, 9), left-inferior parietal lobule (BA area 40), left-inferior temporal gyrus/fusiform gyrus (BA areas 20/37), and left-middle temporal gyrus (BA area 21). There are also studies with different approaches, such as identifying ectopias clustered round the left temporoparietal language areas. [[Stein-1]]

Different schools of research have championed different neurological bases of dyslexia and its resulting subgroups.

Auditory Discrimination

(Main research - see Tallal et all [[Tallal-1]].) This body of research has shown that many people with dyslexia have defects in the left-auditory cortex. The auditory cortex is responsible for sound naming and identification; and temporal processing (such as interval, duration, and motion discrimination).

Note that dyslexia does not affect hearing, but the identification and differentiation of sounds.

Visual Recognition Skills

(Main school of research Livingstone (1993) and Martin and Lovegrove 1988). See [[Eden-1]], [[Henderson-1]].) People with dyslexia have reduced synaptic activity in the V5 area (also known as visual area MT, middle temporal), which is a region of extra-striate visual cortex thought to play a major role in the perception of motion.

V5 is part of the broader "magno-cellular -- large cell -- system" that processes fast-moving objects, and brightness contrasts. One interpretation is that a specific magno-cellular cell type develops abnormally in people with dyslexia (3).

For results of clinical tests see (1).

Phoneme Processing

Main research from Shaymitz (1998) and Rumsy (1996). (See [[Eden-1]], [[Paulesu-1]], [[Rumsey-1]], [[Henderson-1]], [[Demonet-1]], [[Pugh-1]], [[Petersen-1]].) The language regions in the superior-temporal gyrus (Wernike's area) and striate cortex are found to underachieve in people with dyslexia. These areas respond to simple phoneme processing tasks. (Areas that respond to more complex language tasks, an anterior region, the IFG, displayed relative over-activation in people with dyslexia.)

Games involving nonsense words, rhyme, and sound manipulation will be enhanced by special auditory effects: Consonants are recorded louder while the adjacent vowel is lengthened and its sound softened. All games are carefully leveled by the complexity of the manipulations involved. (For results of clinical tests, see Ojemann 1989, Bertoncini et. al., 1989).

Cross-modal Association

Main research from Leon (1996) and Shaymitz (1998). (See [[Lyon-1]], ( [[Black-1]], pages 331–376), [[Benson-1]], [[Dejerine-1]], 30.)

The angular gyrus, a brain region considered pivotal in carrying out cross-modal (e.g., vision and language) associations necessary for reading, is involved. Current findings of under-activation in the angular gyrus of readers with dyslexia coincide with earlier studies of those who lost the ability to read due to brain damage centered in that same area of the brain.

The ability to link visual stimuli to auditory interpretation can be stimulated by multimedia implementation of the coming together of these separate disciplines. Activities are all carefully leveled to correlate a current ability level.

Visual Recognition Skills

(Main school of research Livingstone (1993) and Martin and Lovegrove (1988).) (See [[Eden-1]], [[Henderson-1]].) People with dyslexia have reduced synaptic activity in the V5 area.

For results of clinical tests see (1).

Working Memory

(Main school of research Beneventi et. al., 2008.)

Reduced activity in the pre-frontal and parietal cortex may result in working memory deficits. [[Berninger-1]]

Symptoms

Common symptoms are:

slow and laborious reading (If people are undiagnosed or diagnosed late, they may be illiterate or barely literate.);
Concentration tends to fluctuate.
poor and unusual spelling and grammar (Handwriting is unusable or very messy.);
poor physical coordination;
difficulty remembering information (tends to fluctuate);
difficulty with organizing and planning.
difficulty working within time limits;
difficulty thinking and working in sequences, which can make planning difficult;
visual processing difficulties, which can affect reading and recognizing places;
poor auditory processing skills, which can make listening to oral instructions difficult, tiring and confusing.

Challenges

Memory

Poor short term memory for facts, events, times, dates, symbols.
Poor working memory, i.e., difficulty holding on to several pieces of information at the same time. This is especially challenging while undertaking a task, e.g., taking notes while listening, addressing compound questions.
Mistakes with routine information, e.g., providing age, phone number, or ages of children.
Inability to hold on to information without referring to notes.

Automatizing Skills

People with dyslexia do not tend to automatize skills very well. A high degree of mental effort is required in carrying out tasks that typical individuals generally do not feel requires effort. This is particularly true when the skill is composed of several sub-skills (e.g., reading, writing, driving).

Information Processing.

Difficulties with taking in information efficiently (could be written or auditory).
Slow speed of information processing, such as a 'penny dropping' delay between hearing or reading something and understanding and responding to it.

Communication Skills

Lack of verbal fluency and lack of precision in speech (relevant for voice systems).
Word-finding problems.
Inability to work out what to say quickly enough.
Misunderstandings or misinterpretations during oral exchanges.
Sometimes, mispronunciations or a speech impediment may be evident.

Literacy

Difficulty in acquiring reading and writing skills. Reading is likely to be slow.
If people are undiagnosed or diagnosed late, they may be illiterate or barely literate.
Where literacy has been mastered, problems continue, such as poor spelling; difficulty extracting meaning from written material; difficulty with unfamiliar words; and difficulty with scanning or skimming text.
Particular difficulty with unfamiliar or new language, such as jargon.

Organization, Sequencing

Difficulty organizing a sequence of events.
Incorrect sequencing of strings of numbers and letters (passwords, phone numbers).
Chronic disorganization and misplacing/losing items.
Difficulty with time management and passage of time.

Navigation

Difficulty with finding the way to places or navigating - even in the context of a building. Often get lost.

Lack of Awareness

Failure to notice body language.
Failure to realize consequences of their speech or actions.

Visual Stress

Some people with dyslexic difficulties may experience visual stress when reading especially when dealing with large amounts of text. So, breaks are often needed.

Coping Strategies

It must be emphasized that individuals vary greatly in their learning difficulties. Key variables are the severity of the difficulties; the ability to identify and understand their difficulties; and successfully developing and implementing coping strategies.

By adulthood, many people with dyslexia are able to compensate through technology, reliance on others, and an array of self-help mechanisms, the operation of which requires sustained effort and energy. Unfortunately, these strategies are prone to break down under stressful conditions, which impinge on areas of weakness.

Effects of Stress

People are particularly susceptible to stress (compared with the ordinary population) with the result that their impairments increase.

Scenarios and User Stories

Scenario: Online Research

A is a high school student with dyslexia. Although he can read, his level is slow and he finds it difficult. A has a school project and needs to do online research. A does not use a screen reader because he is afraid it will stop him from reading and improving his skills. A needs to be able to find content he needs easily. This includes finding the right resource and the right information inside that resource with minimal reading. He will then read the sections that he needs. He will do a web search, and a quick review of different pages to find the pages he needs.

Table of ICT Steps and challenges
Step	Challenge
Search query
Scanning results
Doing a short review of different options and finding the most appropriate.
Finding the right content in the right document.
Reading the right content.
Collecting the information.
Copying for citing resources and collecting them with the right information.
Saving the work.
Putting it together and writing the paper.	Out of scope of this use case.

Scenario: Finding Out About a Change Event in an Email

B is a mother with young children. She has dyslexia. B reads words, then stops to understand them. B is also a slow reader. B receives many emails. Important emails often are below or behind the scroll bar. Reading summaries of each email takes time. B has set her email app to tag emails from her child's school as important. However, B still needs to differentiate between emails from her child’s school that are crucial, and emails that are just informative. B needs to be able to find important content (such as school finishing at a different time next Monday) in a long school newsletter.

B’s email application changes, and she no longer knows how to tag senders as important. At the same time, her child starts at a new school. B has difficulty finding the information on how to tag emails from the new school as important. Also, the school starts sending many emails about projects her child is doing, and what is happening in class, so B does not have time to read each email as soon as it arrives. She postpones this task and important emails get lost.

Table of ICT Steps and challenges
Step	Challenge
Finding out how to tag/label this from a sender as important (first time).
Remembering the process (re-finding it next time).
Tagging/labeling the new teacher.
Identifying important emails from the teacher, and distinguishing them from general interest-emails.
Finding important content in long emails.

Scenario: Using a Electronic Interface

C is an adult living alone. He has dyslexia. C has impaired vision and auditory memory; and finds remembering sequences extremely challenging. C has a garden with an automatic watering system that has a one line (electronic) interface. The interface is not user friendly. C needs to select which sprinkler he is setting using an arrow key; then set the first time it should go on (using the arrow key in the number mode); then press enter; and then set the duration the sprinkler should run. He then needs to repeat the steps for the second time (or leave it blank). He then needs to repeat the process for the next sprinkler in the correct order. C has been shown how to use the system many times. However, each time the system needs to be adjusted, he makes mistakes and gets confused. Ten years later C still needs to call the gardener to change the settings, and is consonantly relearning the interface.

Table of ICT Steps and challenges
Step	Challenge
Learning the steps involved.	Learning the sequence.
Performing the steps correctly.	Remembering the sequence. Performing it in the correct order.
Undoing mistakes.	Remembering at which point he is in the sequence. Going back a step, and tracking the step he is at now.

Scenario: Using a Phone Menu

D is looking after his elderly father. D has dyslexia and impaired working memory; and impaired auditory discrimination. D can do one mental process at a time. D is weak at remembering numbers. He can remember one number at a time. D typically makes mistakes when dialing numbers. Often he will dial a number 3 or 4 times before he gets it right. D needs to speak to a doctor about his father who is sick. The doctor's office has a phone system with multi-layers. It takes D two attempts to dial the office. When faced with the menu system, D needs to listen to several similar options, understand the words, process the words, make a choice, identify the correct number, and enter the correct number into the keypad. Because he is trying to remember numbers whilst he is trying to listen to the next option, he misunderstands the options. He makes an incorrect choice. When trying to recover from the error he enters an invalid number and gets thrown off the line. D needs to redial this number but, as he is now upset, it takes him four attempts to dial it correctly. He is then faced with the same phone system. D makes more mistakes. After half an hour, he asks a neighbor to help him. D is very upset, which in turn upsets his sick father. D's self confidence at being able to look after his father is shattered.

Table of ICT Steps and challenges
Step	Challenge
Identifying the option he needs and remembering the right number associated with that option.	Auditory discrimination under pressure; memory of the correct number whilst listening and processing other options.
Entering the correct number.	Mapping the symbol to the number under pressure; eye-hand coordination.
Undoing mistakes.	Staying calm so his skills do not further deteriorate.

How They Use The Web and ICT

People with dyslexia tend to use mainstream technologies (e.g., a spell checker) to help them. They may use screen readers that highlight text as they read. They may use other assistive technology, such as Dragon or a Daisy reader, though they seem to be used more as teaching aids rather than typical Web access. Special software to help dyslexics includes Text Help.

Characteristics of Content Optimized For This Group

Content made for people with dyslexia tends to have:

icons to visually reinforce structure and what each section is (such as examples, tips etc.);
diagrams that illustrate the point of the content;
short paragraphs, short sentences;
a beginning-summary of the point. (This can also be true at the document or paragraph level, where the first sentence raises the main point of the paragraph.);
well-structured text with headings (reducing reading of irrelevant text);
use of bold on key terms (helps finding of relevant text);
a "read it to me" button, that highlights text as it is read, and is simple to use;
a clear, well-structured, minimalistic-navigation system, which is free from confusing steps and a complex user-interface flow.

In general, content for people with dyslexia helps users find the text they are looking for via visual aids, and reduces the need to read though irrelevant text to find the information that they are looking for.

Specific Technologies

Assistive technologies include (incomplete list):

Text help
Dragon
Kurzweil
Ghotit
Learning Ally
Zoomreader
Speak-it
Read2Go

Summary of Existing Research and Guidelines

There are organizations that have produced guidelines for creating content for people with dyslexia, such as The British Dyslexia Association, and The Irish Dyslexia Association. Note that we are not recommending them, just summarizing them for further review.

Summary/Exerts of The British Dyslexia Association Guidelines and Dyslexia Style Guide

This Guide is in three parts: 1. Dyslexia Friendly Text. 2. Accessible Formats. 3. Website design.

Dyslexia-Friendly Text

The aim is to ensure that written material takes into account the visual stress experienced by some people with dyslexia, and to facilitate ease of reading. Adopting best practices for readers with dyslexia has the advantage of making documents easier on the eye for everyone.

Media

Use a plain, evenly-spaced, sans-serif font, such as Arial. See the BDA New Technologies Committee website: http://bdatech.org/what-technology/typefaces-for-dyslexia/
Font size should be 12-14 point. Text should be expandable.
Use dark-colored text on a light (not white) background. (Avoid pure white backgrounds because of glare.)

Headings and Emphasis

For Headings, use a larger-font size in bold, lower case.
Boxes and borders can be used for effective emphasis.
Avoid underlining and italics. These tend to make the text appear to run together. Use bold instead.
AVOID TEXT IN BLOCK CAPITALS. It is much harder to read.

Layout

Use left-justified text with a ragged-right edge.
Avoid narrow columns (as used in newspapers).
Use lines of text that are not too long: 60 to 70 characters.
Avoid cramping material and using long, dense paragraphs: space it out.
Use text line spacing of 1.5.
Avoid starting a sentence at the end of a line.
Use bullet points and numbering rather than continuous prose.

Writing Style

Use short, simple sentences in a direct style.
Give instructions clearly.
Avoid long sentences of explanation.
Use active rather than passive voice.
Avoid double negatives.
Be concise.

Increasing Accessibility

Flow charts are ideal for explaining procedures.
Pictograms and graphics help locate information.
Lists of do's and don't's are more useful than continuous text to highlight aspects of good practice.
Avoid abbreviations if possible, or provide a glossary of abbreviations and jargon.
For long documents, include a contents page at the beginning and an index at the end.

Checking Readability

Note: The spell checker in MS Word can be set to automatically check readability. MS Word will then show the readability score every time spelling is checked.

Check long documents in sections to determine which parts are too hard to read.
Flesch Reading Ease score: Rates text on a 100-point scale. The higher the score, the easier it is to understand the document. For most standard documents, aim for a score of approximately 70 to 80.

Flesch-Kincaid Grade Level score: Rates text on a U.S. grade-school level. For example, a score of 5.0 means that a fifth grader, i.e., a Year 6, average 10 years old, can understand the document. For most standard documents, aim for a score of approximately 5.0 by using short sentences, not by simplifying vocabulary.

Accessible Formats

Use an accessible format so content can be read by screen-reading software.

Offer both the source MS Word files and derived PDF files where possible.
Publicize availability of accessible formats.

Preparing a Document for Text-Reading Software

Listening to a document using a text reader will take longer than visual reading.
Place semi-colons, commas, or periods after bullet points and headings to make the screen-reader voice drop and pause. (A pale tint similar to the background color will make the punctuation less visually distracting.)
Use Styles in MS Word to organize headings and formatting.
Use hyperlinks for Contents-Page listings.
Number menu items.
Use internal and external hyperlinks for ease of navigation.
Avoid capital letters in mid-line, as they may be read as single letters.
Include as few signs and symbols as are absolutely necessary, e.g., asterisks or dashes (both short and long), as these will be spoken.
Long dashes should be avoided. Use colons to make the voice pause.
Use straight quotation marks. Curly or slanting ones may be read as ‘back quote’ by some screen readers.
Avoid Roman Numerals and 'No.' for number.
Consider whether abbreviations and acronyms need periods.
Use hyphens in compound words to aid text-reading pronunciation.
Chunk phone numbers to avoid being read as millions or hundreds of thousands.

Website Design

Research shows that readers with dyslexia access text at a 25% slower rate on a computer. This should be taken into account when putting information on the web. When a website is completed, check the site and information for accessibility by carrying out these simple checks.

Navigation should be easy. A site map is helpful.
Use graphics, images, and pictures to break up text, while bearing in mind that graphics and tables may take a long time to download.
Very-large graphics make pages harder to read.
Offer alternate-download pages in a text-reader-friendly style.
Where possible, design web pages that can be downloaded and read off-line.
Don't use moving text, which creates problems for people with visual difficulties. Text-reading software is unable to read moving text.
In a table of contents, set hyperlinks so they show which pages have been accessed.
Encourage the use of hyperlinks at the end of sentences.
Make sure it is possible for users to set their own choices of font style and size and background and print colors.

Other Guidelines

Tips found across the web include the following. Dyslexia.com

Keep paragraphs short, and use a small amount of text on each page.
If a long article is posted, create a topic index at the beginning so that a reader with dyslexia can quickly narrow in on the parts that interest him or her.
Use default-font settings, or provide a way for users to choose their own styles.
Use small icons to help with navigation between frequently-used web pages.
Avoid using background images behind text. Make sure there is a good contrast between the color of the background and the color of the text.
Do not set up background music to play, unless the site gives the user a choice whether to turn it on.

Extent To Which Current Needs Are Met

WCAG does help in that content can be used by a screen reader and headings should be used. Many of the most useful checkpoints are AAA, and hence not implemented, or are advisory techniques and hence, likewise, not adopted.

AA level conformance to WCAG does not significantly help reduce cognitive load or reduce dependency on text by formatting and pictorial aids. Other guidelines (non W3C such as British Dyslexia Association Guidelines) fill in some of the gaps in WCAG.

None of the reviewed guidelines help ICT interfaces of voice-mail systems. They also do not address getting additional help.

Potentials and Possibilities

Added to brainstorming section

Prevalence

Dyslexia is a hidden disability thought to affect around 10% of the population, 4% severely.

Note that recent studies indicate dyslexia is particularly prevalent among small-business owners, with roughly 20 to 35 percent of US and British entrepreneurs being affected. This is important, as often people feel people with dyslexia are not in their user audience. With the exception of a scrabble game site, that is very unlikely. [39]

Sources and References

http://www2.open.ac.uk/study/support/disability/orientation

http://www.bdadyslexia.org.uk/dyslexic/adult

References to Research

1. Bakker, (1990) Neurophysiological Treatment of Dyslexia, Oxford University Press,.

3. Getting the Message Across, published by the Questions Publishing Company, Birmingham, England, 1996, on behalf of the British Dyslexia Association.

30. Friedman, R. F., Ween, J. E. & Albert, M. L. (1993) in Clinical Neuropsychology, eds. Heilman, K. M., Valenstein, E. (Oxford Univ. Press, New York), pp. 37–62.

39. Brent Bowers (2007-12-06). "Tracing Business Acumen to Dyslexia". New York Times.Cites a study by Julie Logan, professor of entrepreneurship at Cass Business School in London, among other literature.

Aphasia include

Non-verbal - Severe Speech and Language impairments

Communication Difficulties and Disorders may include non-verbal individuals such as those who have Aphonia with no vocal output, Anarthria where speech musculature is involved and other disabilities that preclude any form of speech and language. The description may also include those with Aphasia who may have receptive and expressive difficulties (see section - Aphasia), Dysarthria and dyspraxia where words may become unintelligible and a wide range of other difficulties that make articulation of accurate sounds difficult, language expression and understanding hard to achieve and vocalization impossible. This can include those who have hearing impairments and cognitive disabilities but in this section the concentration is on those who use Augmentative and Alternative Communication (AAC).

"Augmentative and alternative communication (AAC) includes all forms of communication (other than oral speech) that are used to express thoughts, needs, wants, and ideas. We all use AAC when we make facial expressions or gestures, use symbols or pictures, or write." [[ASHA-2]]

Cognitive Functions

These may be impaired and affect the choice of symbols and devices used to support communication needs. The impact of severe cognitive impairment affects all aspects of speech and language with possible reduced expressive and receptive abilities. There may be difficulties in the composition of words, phrases and sentences and also the understanding of them whether represented by symbols, gestures or other methods of communication.

Memory
Cognitive impairments may result in impaired short term memory which can impact on learning how to use any symbolic representations of speech such as pictograms and other photographic symbols. This may result in a very reduced number of symbols being used on a daily basis. Lack of Auditory memory affects the ability to gain skills in phonemic awareness that aids literacy skills. Difficulties with visuo-spatial memory impact on the speed withwhich symbols may be found on a communication board or located on a screen and with physical difficulties this can further slow communication. Procedural memory difficulties result in poor automaticity in terms of Language Acquisition through Motor Planning (LAMP) which is one of the ways individuals can speed their AAC output.

Reasoning
Where intellectual capacity is affected there may be issues with reasoning, learning and thus remembering plus abstraction.

Attention
Shortened attention span can occur alongside distractability when other cognitive impairments are present.

Language
Young AAC users may have difficulty developing good sentence construction for written language in particular if reading skills are poor

Speech Perception
Cognitive impairments can affect speech perception

Understanding Figurative Language
Idioms, metaphors, similes and other representations of language that contain abstract notions can cause issues for AAC users

Literacy
Aquired dyslexia can be an issue with individuals having to relearn how to read, sound out words and remember how to spell.

Visual Perception
Not recognising letters and words impact on reading and even object recognition can be affected

Other Perception
Auditory perceptual difficulties can affect phonemic awareness and any possible speech output

Knowledge
An AAC user does not necessarily have intellectual difficulties but knowledge can be trapped within the brain if the individual cannot express their thoughts.

Behavioral
Behaviour can be affected by the inability to communicate with considerable frustration occurring at times. Individuals may also become depressed and irritable, however these individuals can also show amazing resilience and understanding when issues arise.

Consciousness
Consciousness in those who have no communication skillscan be difficult to assess

Symptoms

Anarthria: Loss of the motor ability that enables speech. Complete loss of the ability to vocalize words as a result of an injury to the part of the brain that is responsible for controlling the larynx.

Aphasia: A disturbance of the comprehension and formulation of language caused by dysfunction in specific brain regions. There may be an inability to read, naming problems (finding the right word to refer to something), mis-articulated words, grammatical errors in speech, difficulty with numerical calculations, slow and effortful speech, inability to compose written language or inability to understand speech.

Apraxia: An acquired oral motor speech disorder affecting an individual's ability to translate conscious speech plans into motor plans.

Autism: A disorder of neural development characterized by impaired social interaction and verbal and non-vocal communication.

Aphonia: The inability to produce voice.

Alalia: A delay in the development or use of the mechanisms that produce speech.

Dyslalia: Difficulties in talking due to structural defects in speech organs.

Developmental verbal dyspraxia: Motor speech disorder involving impairments in the motor control of speech production.

Developmental Disabilties: Fragile X, Down syndrome, pervasive developmental disorders, fetal alcohol spectrum disorders, cerebral palsy.

Intellectual Impairment: traumatic brain injury, lead poisoning, Alzheimer's disease.

Challenges

The following rights are summarized from the United States of America's Communication Bill of Rights put forth in 1992 by the US National Joint Committee for the Communication Needs of Persons with Severe Disabilities. [[ASHA-3]]

"All people with a disability of any extent or severity have a basic right to affect, through communication, the conditions of their existence. All people have the following specific communication rights in their daily interactions.

Each person has the right to

request desired objects, actions, events and people
refuse undesired objects, actions, or events
express personal preferences and feelings
be offered choices and alternatives
reject offered choices
request and receive another person's attention and interaction
ask for and receive information about changes in routine and environment
receive intervention to improve communication skills
receive a response to any communication, whether or not the responder can fulfill the request
have access to AAC (augmentative and alternative communication) and other AT (assistive technology) services and devices at all times
have AAC and other AT devices that function properly at all times
be in environments that promote one's communication as a full partner with other people, including peers
be spoken to with respect and courtesy
be spoken to directly and not be spoken for or talked about in the third person while present
have clear, meaningful and culturally and linguistically appropriate communications"

How Symptoms result in Challenges for Young People who are Non-Verbal

Young non-vocal communicators are very often encouraged to make vocal speech and all efforts are made to achieve that goal. There is a persistent idea that if AAC systems are introduced early in a child’s life it will delay or prevent the development of verbal speech. This conclusion is erroneous. Research (http://www.pecsusa.com/research.php) has shown that the introduction of AAC early in a child’s life will actually help the child develop verbal speech if that capability exists. The emphasis on making verbal speech still continues after AAC is introduced, but the fact that the child now has a means of communicating means that their right to communicate is already being supported. In situations where Speech and Language Pathologists (SLP) attempt to introduce AAC early the challenge to enlist the family/caregivers as supporters of AAC often fails. In situations where no SLP is available and/or the knowledge that there are relatively inexpensive interventions available and/or the parents/caregivers do not support the system, the child is not supported with an AAC system and expectations fall far short of the child's potential.

Major Challenges:

No Support

Because very special conditions must be present to support a non-vocal communicator with AAC (resources, knowledge, support) non-vocal people are often not helped to develop even low-tech communication systems. This leads to vastly reduced opportunities for the non-vocal communicator. In individuals for whom functional level prohibits using AAC tools, there are other strategies such as indirect selection, facial expression, vocalizations, gestures, and sign languages.

Non-Interoperability

Since high-tech AAC systems almost always have different operating systems and file structures, each time a new device is added someone has to manually re-program the communication system. This non-interoperability problem exists across almost all devices, even extending to multiple devices developed within by a single manufacturer. This is a major challenge facing most non-vocal people using high-tech AAC systems.

Costs of Low-Tech AAC

Communication books, symbol sets and software to customize and print icons, activity boards, picture schedules, and other low-tech communication tools are relatively inexpensive as is training for non-vocal people, SLPs, and parents/caregivers. Inexpensive is a relative term, and many communities do not have resources for even the basic tools, but if a basic methodology is employed, then even makeshift tools will enable some communication beyond making sounds, pointing, and gesturing.

Costs of High-Tech AAC

High-tech AAC systems are expensive as are extended warranties. The life of a device is usually limited to the life of the extended warranty offered by the manufacturer. This is due not only to the expense involved in supporting an out-of-warranty device but also to the fact that parts become scarce when devices are discontinued and manufacturing stops. Medicare standards (in the US?) prohibit the purchase of a new device until five years from the purchase date of the previous device so insurance companies and institutions follow that pattern. This makes the de-facto life of high-tech AAC devices five years, and this is echoed by manufacturer warranties which typically extend coverage to five years.

Costs of Lack of AAC

There are costs associated with failing to implement AAC. These costs include social and health consequences for neuro-typical as well as other communicators. AAC introduces a range of behavior modification techniques for non-neuro-typical individuals. Example: use of a picture schedule creates the opportunity for frictionless transitions in individuals for whom transitions are difficult and who may act out their fears with self-harming or other behaviors.

Scenarios and User Stories

Young Non-Verbal Woman

S is a 21 year old woman with a chromosomal deletion known as Cri-du-chat Syndrome, or Five P Minus (5p-). She is a mosaic; she has the transcription error in approximately 50 percent of her cells, so some of the classic Cri-du-chat symptoms are not present such as congenital heart problems and microcephaly. S has orthopedic impairments, is ataxic (loss of full control of bodily movements) and hypotonic (abnormally low body tone) and she is developmentally disabled. She is also nearly completely non-vocal, but she has a communication system. S uses the Picture Exchange Communication System (PECS) [[PECS-1]] as her base methodology and this is invoked in whatever communication book, picture schedule, choice boards, and other low-tech systems she uses. PECS methodology is also used in her high-tech voice output devices. Using PECS as the base methodology supports her with a consistent approach that has allowed her to develop into a very confident communicator. Since she cannot read or write she relies on icons and pictures to navigate and make her communication choices. She has been using a communication book since she was five years old (and still does) and she started using high-tech AAC systems when she was ten years old. All of her high-tech AAC devices have been purchased from a single vendor, and none of them have been interoperable, requiring her communication environment to be created manually at each change of device. None of her other non-vocal classmates/peers have communication systems.

How They Use the Web and ICT

There are many people who have spoken language communication difficulties who can cope with the use of the web and ICT at a very high level. It can provide their only method for dialogue using e-mail, instant messaging, social media etc. Individuals with cognitive disabilities as well as communication difficulties may on the other hand struggle with elements of Internet usage. They may find the intricacies of navigation, complex content and confusing messaging systems hard to access.

There remains a lack of suitable systems that are simple enough for symbol users to engage with a wide range of social networks, email and voice systems. Users generally need to use bespoke software that allows for symbol to text and text to symbol conversions. Use of the web is hampered by a lack of symbol based informational sites - simple word to symbol translation does not always solve comprehension problems.

Characteristics of Content Optimized for This Group

Those who have developmental speech and language disorders and make use of AAC may have difficulties learning to read or may not have the cognitive capacity to learn to read and so there are considerable challenges producing web content and technologies that can support this user group. However, there are also huge benefits for these individuals if they can access the web in terms of interactive communication and socialisation. Features that can help include

Bold type for headings and keywords
Introduce high levels of white space, short paragraphs, larger than usual sans serif fonts and increased line spacing.
Offer increased sizes for menu buttons and media controls.
Clear and unambiguous use of images with good contrast levels.
Simple alternative tags and text explanations for media items.
Clear short sentence structure with use of concrete concepts for easy reading.
Use of first person whilst also avoiding conditional tenses.
Offer speech output for all main content - text to speech or recorded speech files embedded on the website.
Use colour to delineate areas with logical keyboard accessible navigation
Static content for the main areas of a website with meaningful use of dynamic content if necessary.
Increased levels of complexity related to content should be available on secondary pages for those who have higher level literacy skills.

Specific Technologies

Specific technologies that can help those who have communication difficulties vary enormously. They range from simple text to speech that can aid reading ability, the highlighting of text as items are read aloud, enlarged font sizing and different font styles to complex communication aids.

There are a wide range of systems including unaided AAC systems that do not require an technologies but may include facial expression, vocalizations, gestures, and sign languages. Then there are the low-tech communication aids which may be defined as those that do not need batteries, electricity or electronics such as communication books and boards. High-tech communication systems can include speech generating devices and software for computers, tablets, and smart phones.

Specific groups of AAC users will use different types of symbols and devices. They include those with: cerebral palsy, intellectual impairment, autism, developmental verbal dyspraxia, traumatic brain injury (TBI), aphasia, locked-in syndrome, amyotrophic lateral sclerosis, Parkinson's disease, multiple sclerosis, dementia.

Types of symbol AAC methodologies:

Picture Exchange Communication System (PECS),
MinSpeak etc
LAMP

Symbol sets:

Bliss symbols
Symbol Stix
PCS
Widgit
ARASAAC
Sclera

Extent To Which Current Needs Are Met

Those who use AAC devices often depend on symbols for communication and may have poor literacy skills or if they do have good literacy skills they may struggle to fill in forms and online documentation due to other physical disabilities. It is essential that there is an understanding of the slowness of interaction that might take place with challenging touch screen, keyboard or switch access. At present very few websites offer:

Integrated speech output to support textual content
Total keyboard accessibility that can be translated to switch access
Alternative navigational elements that are clear and large enough for touch screen use
Chances to adapt the look and feel of pages to suit user needs - font sizing, colour backgrounds, decluttering to aid readability
Use of colour to aid comprehension and highlight key points.
Images and icons that can explain content

Potentials and Possibilities

It is possible to link to symbol databases to offer options for symbols to appear that can explain the meaning of words. This system is used by Widgit Online Point There is the problem of words having more than one meaning and several symbols being presented as the system cannot cope with the context of word in a sentence but this will happen in time.

Browsers and Websites can offer toolbars that allow text to be read aloud with text highlighting, font changing, CSS adaptations and links to services such as Readability

Prevalence

Between 6 and 8 million people in the U.S. have some form of language impairment. Research suggests that the first 6 months of life are the most crucial to a child's development of language skills. For a person to become fully competent in any language, exposure must begin as early as possible, preferably before school age.

Approximately 7.5 million people in the United States have trouble using their voices. Spasmodic dysphonia, a voice disorder caused by involuntary movements of one or more muscles of the larynx (voice box), can affect anyone. The first signs of this disorder are found most often in individuals between 30 and 50 years of age. More women than men appear to be affected. Laryngeal papillomatosis is a rare disease consisting of tumors that grow inside the larynx, vocal folds, or the air passages leading from the nose into the lungs. It is caused by the human papilloma virus (HPV). Between 60 and 80 percent of laryngeal papillomatosis cases occur in children, usually before the age of three. Speech Source: Compiled by NIDCD based on scientific publications.

The prevalence of speech sound disorders in young children is 8 to 9 percent. By the first grade, roughly 5 percent of children have noticeable speech disorders; the majority of these speech disorders have no known cause. By the time they are six months old, infants usually babble or produce repetitive syllables such as "ba, ba, ba" or "da, da, da." Babbling soon turns into a kind of nonsense speech jargon that often has the tone and cadence of human speech, but does not contain real words. By the end of their first year, most children have mastered the ability to say a few simple words. By 18 months of age, most children can say 8 to 10 words. By age 2, most put words together in crude sentences such as "more milk." At ages 3, 4, and 5, a child's vocabulary rapidly increases, and he or she begins to master the rules of language. It is estimated that more than 3 million Americans stutter. Stuttering can affect individuals of all ages, but occurs most frequently in young children between the ages of 2 and 6. Boys are 3 times more likely than girls to stutter. Most children, however, outgrow their stuttering, and it is estimated that fewer than 1 percent of adults stutter. Compiled by NIDCD based on scientific publications. [[NIDCD-1]]

References to Research

The bibliographic entries below need to be moved to inline citations. Once this is done, this section will be deleted.

W3C (2014) Research Report on Easy to Read on the Web Editors' Draft 23 January 2014 http://www.w3.org/WAI/RD/2012/easy-to-read/note/ED-E2R-20140123 [[RDWG-1]]

Clarke M, Lysley A, Nicolle C and Poulson D (2002) World Wide AAC: Developing Internet Services for People using AAC. In: Proceedings of ISAAC 2002 10th Biennial Conference of the International Society for Augmentative and Alternative Communication, 10-15 August 2002, Odense, Denmark

Communication Matters (2013) Shining a light on Augmentative and Alternative Communication http://www.communicationmatters.org.uk/shining-a-light-on-aac [[communication-matters-1]]

Pistorius,M. (2011) 'Communication: An AAC User's Perspective', Communication Matters Conference 2011 [[Pistorius-1]]

United Nations Expert Meeting on Building Inclusive Societies and Development through Promotion of Accessible Information and Communication Technologies (ICTs); Emerging issues and trends Tokyo, Japan, 2012, http://www.un.org/disabilities/ [[UN-1]]

The Bercow Report: A Review of Services for Children and Young People 0 to 19 with Speech, Language and Communication Needs, 2008 http://dera.ioe.ac.uk/8405/1/7771-dcsf-bercow.pdf [[Bercow-1]]

Glossary

Communication Disorders

The American Association of Speech-Language-Hearing Association (ASHA) definition for communication disorders is as follows: "A communication disorder is an impairment in the ability to receive, send, process, and comprehend concepts or verbal, nonverbal and graphic symbol systems. A communication disorder may be evident in the processes of hearing, language, and/or speech. A communication disorder may range in severity from mild to profound. It may be developmental or acquired. Individuals may demonstrate one or any combination of communication disorders. A communication disorder may result in a primary disability or it may be secondary to other disabilities. - See more at: http://www.asha.org/policy/RP1993-00208/"

Cognitive Functions

Cognitive function as "an intellectual process by which one becomes aware of, perceives, or comprehends ideas" (Mosby, 2009)may or may not be tied directly to a communication disorder. An individual may have high cognitive functioning and still be unable to communicate.

Aging include

Intellectual Disability

"Intellectual disability is a condition diagnosed before age 18 that includes below-average intellectual function and a lack of skills necessary for daily living. It is typically characterized by:

Lack of or slow development of motor skills, language skills, and self-help skills, especially when compared to peers
Failure to grow intellectually or continued infant-like behavior
Lack of curiosity
Problems keeping up in school
Failure to adapt (adjust to new situations)
Difficulty understanding and following social rules"

Source: U.S. National Institutes of Health

Education and proper care has been shown to improve quality of life. Some children with an intellectual disability are educated in typical-school classes, while others require more-specialized education. Some individuals with intellectual disability graduate from high school, and a few attend post-secondary education.

"Intellectual disabilities" are known as "learning disabilities" or as "learning difficulties" in the United Kingdom. In the United States, "intellectual disability" used to be known as "mental retardation", a term that is no longer used.

Cognitive functions

This section is a technical reference. Jump to the next section on Symptoms for more practical information.

Overview

"One way to measure intellectual functioning is an IQ test. Generally, an IQ test score of around 70 or as high as 75 indicates a limitation in intellectual functioning."

Significant deficits in adaptive behavior are another way to identify people with intellectual disabilities. "Adaptive behavior is the collection of conceptional, social, and practical skills that are learned and performed by people in their everyday lives."

"Conceptual skills—language and literacy; money, time, and number concepts; and self-direction.
Social skills—interpersonal skills, social responsibility, self-esteem, gullibility, naïveté (i.e., wariness), social problem solving, and the ability to follow rules/obey laws and to avoid being victimized.
Practical skills—activities of daily living (personal care), occupational skills, healthcare (sic), travel/transportation, schedules/routines, safety, use of money, use of the telephone.

Standardized tests can also determine limitations in adaptive behavior.

This condition is one of serveral (sic) developmental disabilities—that is, there is evidence of the disability during the developmental period, which in the US is operationalized as before the age of 18."

Source: American Association on Intellectual and Developmental Disabilities

Auditory Discrimination

People with intellectual disabilities often struggle with short-term auditory memory. Most people use memory to process, hold, understand, and assimilate spoken language. Auditory memory relates directly to the speed with which words can be articulated, and influences the speed at which people learn new words and learn to read.

Theories about memory suggest words that are heard are received and stored in working memory to make sense of them. They are then transferred to a more long-term store. However, words are only retained in the working memory for two seconds unless consciously kept there by silently repeating them to oneself, called rehearsing. The amount of information that can be retained within the two-second span is called the auditory digit span.

Is there a relationship between intellectual disability and working memory?

Yes, many people with intellectual disabilities have difficulties in this area. Generally, long-term memory is not impaired. Neither is the visual memory, which is often far stronger.

Source: Sandy Alton

Visual-Recognition Skills

The cognitive profile observed in intellectual disability is typically uneven, with stronger visual than verbal skills; receptive vocabulary stronger than expressive language and grammatical skills; and often strengths in reading abilities. There is considerable variation across the population of people with intellectual disabilities.

Many studies have included typically-developing children matched for chronological age, for non-verbal mental age, or on a measure of language or reading ability. Individuals with intellectual disability have also been compared to individuals with learning difficulties of an unknown origin, and to individuals who have learning difficulties of a different aetiology (e.g., specific-language impairment).

The particular measures of language, reading, or non-verbal ability, used for matching, can affect the conclusion drawn. There are also behavioral aspects of intellectual disability other than non-verbal ability and language ability (such as motivational style), which may affect performance on tasks, including attainment tests, and need to be taken into account.

In terms of education, there is strong evidence to suggest that the relatively-recent policy of educating children with intellectual disability in mainstream schools has had a positive effect on language skills and academic attainments. This means that the findings of studies conducted a number of years ago need to be interpreted with caution.

Source: Margaret Snowling, Hannah Nash, and Lisa Henderson

Symptoms

Intellectual and cognitive impairment, and problems with thinking and learning, usually range from mild to moderate. Common symptoms are:

short attention span;
poor judgment;
impulsive behavior;
slow learning;
delayed language and speech development;
reading is typically slow and laborious. (If people are undiagnosed or diagnosed late, they may be illiterate or barely literate.);
concentration tends to fluctuate;
poor and unusual spelling and grammar;
handwriting is unusable or very messy;
poor physical coordination;
difficulty remembering information (tends to fluctuate);
difficulty with organizing and planning;
difficulty working within time limits;
difficulty thinking and working in sequences, which can make planning difficult;
visual processing difficulties, which can affect reading and recognizing places;
poor auditory processing skills;
listening to oral instructions difficult, tiring and confusing.

Symptoms vary with each person, and appear at different times in their lives.

Source: U.S. National Institutes of Health

Their Challenges

Memory

Poor short term memory for facts, events, times, dates, symbols.
Poor working memory; i.e., difficulty holding on to several pieces of information at the same time. This is especially challenging while undertaking a task, e.g., taking notes while listening, addressing compound questions.
Mistakes with routine information, e.g., providing age, phone number, or ages of children.
Inability to hold on to information without referring to notes.

Automatizing skills

People with intellectual disability do not tend to automatize skills very well. A high degree of mental effort is required to carry out tasks that other individuals generally do not feel requires effort. This is particularly true when the skill is composed of several sub-skills (e.g., reading and writing).

Information Processing

Difficulties with taking in information efficiently (this could be written or auditory).
Slow speed of information processing, such as a 'penny dropping' delay between hearing or reading something; and understanding and responding to it.

Communication Skills

Lack of verbal fluency and lack of precision in speech (relevant for voice systems).
Word-finding problems.
Inability to work out what to say quickly enough.
Misunderstandings or misinterpretations during oral exchanges.
Sometimes mispronunciations or a speech impediment may be evident.

Literacy

Difficulty in acquiring reading and writing skills. Reading is likely to be slow.
If people are undiagnosed or diagnosed late, they may be illiterate or barely literate.
Where literacy has been mastered, problems continue, such as poor spelling; difficulty extracting meaning from written material; difficulty with unfamiliar words; and difficulty with scanning or skimming text.
Particular difficulty with unfamiliar or new language, such as jargon.

Organization, Sequencing

Difficulty organizing a sequence of events.
Incorrect sequencing of strings of numbers and letters. (passwords, phone numbers)
Chronic disorganization and misplacing/losing items.
Difficulty with time management and passage of time.

Navigation

Difficulty with finding the way to places or navigating, even within a building. Often get lost.

Sensory Sensitivity

Sensitivity to noise and visual stimuli.
Impaired ability to screen out background noise / movement.
Sensations of mental overload.
Tendency to "switch off".

Lack of Awareness

Failure to notice body language.
Failure to realize the consequences of their speech or actions.

Visual Stress

Some people may experience visual stress when reading, especially when dealing with large amounts of text. Breaks are often needed.

Coping Strategies

It must be emphasized that individuals vary greatly in their Specific Learning Difficulties profile. Key variables are the severity of the difficulties; the ability of individuals to identify and understand their difficulties; and successfully develop and implement coping strategies.

By adulthood, many people with Specific Learning Difficulties are able to compensate through technology, reliance on others, and an array of self-help mechanisms, the operation of which requires sustained effort and energy. Unfortunately, these strategies are prone to break down under stressful conditions, which impinge on areas of weakness.

Effects of Stress

People are particularly susceptible to stress (compared with the typical population), resulting in an increase of their impairments.

Some Personas with Use Cases That Address Key Challenges

Scenario A is a high school student with intellectual disability.

Although she can read at a 3rd grade level, reading is slow and difficult. Books geared towards a younger audience with a lot of pictures help. Plus, she can comprehend and remember stories read by others. Test taking is very stressful, It helps when the teacher can help her take the test orally. She is strong on the computer, especially when interested in the topics. She can surf the Web and do research, but needs to be reminded to stay on task and not get distracted by other sites and advertisements. She does not use assistive technology, but has in the past to improve her reading skills. The teacher aide has to remind her to stay on task during exercises. She can do simple research projects, but only if supported with reminders and visual ques.

Table of ICT Steps and Challenges
Step	Challenge
Search query
Scanning results
Doing a short review of different options and finding the most appropriate.
Finding the right content in the right document.
Read the right content.
Collecting the information.
Coping with citing resources and collecting them with the right information.
Remembering the process (re-finding it next time).
Saving the work.
Putting it together and writing the paper.	Her writing is poor, so this would be out of scope for this use case.

How They Use the Web and ICT to Include: Email, Apps, Voice-systems, IM

Add table.

How People with Cognitive Disabilities Use Optimized Content and Special Pages

Add examples with descriptions of features.

Characteristics of Content Optimized for This Group

Add descriptions of key features and how it helps users overcome challenges.

Specific technologies (reference section below and how they use it differently).

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Summary of Existing Research and Guidelines

Aim to ensure that written material takes into account the visual stress experienced by some people with intellectual disability, and facilitates ease of reading. Adopting best practice for readers with intellectual disability has the advantage of making documents easier on the eye for everyone. Font. (Remember people with intellectual disability can be easily distracted and confused.)

Use a plain, evenly-spaced, sans-serif font, such as Arial and Comic Sans. Alternatives include Verdana, Tahoma, Century Gothic, Trebuchet.
Font size should be 12-14 point. Some people with intellectual disability may request a larger font.
Use dark-colored text on a light (not white) background.

Headings and Emphasis

Avoid underlining and italics. These tend to make the text appear to run together. Use bold instead.
AVOID TEXT IN BLOCK CAPITALS. This is much harder to read.
For headings, use larger font sizes in bold, lower case.
Use boxes and borders for effective emphasis.

Layout

Use left-justified text with a ragged right edge.
Avoid narrow columns (as used in newspapers).
Use lines that are not too long: 60 to70 characters.
Avoid cramping material and using long, dense paragraphs. Space it out.
Use line spacing of 1.5.
Avoid starting a sentence at the end of a line.
Use bullet points and numbering rather than continuous prose.

Writing Style

Use short, simple sentences in a direct style.
Give instructions clearly. Avoid long sentences of explanation.
Use active rather than passive voice.
Avoid double negatives.
Be concise.

Increasing Accessibility

Flow charts are ideal for explaining procedures.
Pictograms and graphics help to locate information.
Lists of 'do's and 'don't's' are more useful than continuous text to highlight aspects of good practice.
Avoid abbreviations if possible; or provide a glossary of abbreviations and jargon.
For long documents, include a contents page at the beginning and an index at the end.

Note: The spell checker in MS Word can be set to automatically check readability. MS Word will then show the readability score every time spelling is checked.

Check long documents in sections to determine which parts are too hard to read.
Flesch Reading Ease score: Rates text on a 100-point scale. The higher the score, the easier it is to understand the document. For most standard documents, aim for a score of approximately 70 to 80.

Flesch-Kincaid Grade Level score: Rates text on a U.S. grade-school level. For example, a score of 5.0 means that a fifth grader, i.e., a Year 6, average 10 years old, can understand the document. For most standard documents, aim for a score of approximately 5.0 by using short sentences, not by simplifying vocabulary.

References:

BBC: My web, my way. Making the web easier to use: http://www.bbc.co.uk/accessibility/guides/allguides_index.shtml.

Extent To Which Current Needs Are Met

Review challenges and describe where needs are met. Identify gaps.

Potentials and Possibilities

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Prevalence

Intellectual disability affects about 1% to 3% of the population. There are many causes of intellectual disability, but doctors find a specific reason in only 25% of cases.

Source: U.S. National Institutes of Health

References to Research

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Autism include

Dyscalculia

Dyscalculia is a learning disability specifically-related to mathematics. People with dyscalculia have significant problems with numbers and mathematical concepts, but still have a normal or above-normal IQ. Few people with dyscalculia have problems with math alone. Many also struggle with problems being able to learn to tell time, left/right orientation, rules in games, and much more.

Researchers have yet to come to a final conclusion with just how many types of dyscalculia exist. David Geary has broken the disability down into 4 main areas: semantic-retrieval dyscalculia; procedural dyscalculia; visuospatial dyscalculia; and number-fact dyscalculia. [[Geary-1]]

It should be noted that this is the opinion of just one researcher. There are many other well-established categories for dyscalculia. One such example is published in the Journal of Learning Disabilities, and has arisen from the research of Kosc Ladislav. He has broken Developmental Dyscalculia into 6 areas: verbal, practognostic, lexical, graphical, ideognostical, and operational-developmental. [[Ladislav-1]]

Diana Laurillard (Professor of Learning with Digital Technologies at the Institute of Education, London) - "Although they [individuals with dyscalculia] can count, they do not see the relationships between numbers - e.g., that 5 is made up of 2 and 3. For them, it is just a sequence, like the alphabet. We do not see E as made up of B and C, because it's not. It's just later in the sequence."

The UK DfES (Department for Education & Skills) described dyscalculia in its National Numeracy Strategy:

"Dyscalculia is a condition that affects the ability to acquire arithmetical skills. Dyscalculic learners may have difficulty understanding simple number concepts, lack an intuitive grasp of numbers, and have problems learning number facts and procedures. Even if they produce a correct answer or use a correct method, they may do so mechanically and without confidence."

Cognitive Functions

Genetic, neurobiological, and epidemiologic evidence indicates that dyscalculia, like other learning disabilities, is a brain-based disorder. Some research suggests it may be the result of an altered neural substrate.

It has also been suggested that poor teaching and environmental deprivation may compound the condition [[Shalev-1]].

Because the neural network of both hemispheres comprises the substrate of normal arithmetic skills, dyscalculia can result from dysfunction of either hemisphere, although the left parietotemporal area is of particular significance according to UCL Institute of Cognitive Neuroscience. The debate as to whether the left or right parietotemporal area is linked with dyscalculia is hotly contested. However, there is more research pointing towards a fault in the left parietotemporal area.

There is some research to suggest that dyscalculia may occur as a consequence of prematurity and low birth weight, and is frequently encountered along with a variety of other neurological disorders, such as: attention-deficit hyperactivity disorder (ADHD), developmental-language disorder, epilepsy, and Fragile X Syndrome. Developmental dyscalculia has proven to be a persistent learning disability, at least for the short term, in about half of affected preteen pupils [[Butterworth-1]]. Dyscalculia can also occur later in life as a result of a brain lesion or other traumatic brain injury.

Symptoms

Common symptoms include:

normal/accelerated language acquisition (Good visual memory for the printed word. Good in areas of science, geometry and creative arts until a level of higher math skill is required, and where figures use logic not formula);
mistaken recollection of names (Poor name/face retrieval);
difficulty with abstract context of time and direction;
poor mental math ability;
mistakes commonly made when manipulating numbers;
inability to grasp and remember math concepts;
inability to comprehend or 'picture' mechanical processes;
poor memory of the layout of things;
poor sense of direction;
difficulty grasping concepts of formal music education;
struggles with spatial orientation;
poor athletic coordination;
difficulty when playing games.

Their Challenges

Memory: Poor long-term memory, resulting in an inability to remember names (despite recognizing faces). Inability to recall schedules or sequences, e.g., dance steps and musical-instrument fingering. Unable to remember rules in sports and other games, such as card games. Difficulty remembering whose turn it is.

Numbers: Difficulty with numbers, specifically in cases of addition, subtraction, omission, reversal, and transposition. Inability to count, especially when asked to begin counting at a number other than 1. Particular difficulty with numbers with zeros and their relationships to each other, such as 10, 100, 1000.

Abstract Concepts: Poor concept mastery, resulting in an inability to grasp math concepts. Lack of ability for visualization, such as numbers on a clock face; and recognizing geographical locations and where they are in relation to these locations. Limited capability for strategic planning, such as in chess. Difficulties with spatial orientation, such as distinguishing left from right and north, south, east, and west. Inability to grasp the concept of time or direction, frequently lost/late, trouble telling time. Difficulty handling money. (Many adults with dyscalculia find themselves overdrawn as a result of this.) Difficulty in planning for long term with a tendency to focus on the present or the near future.

Coordination: Poor athletic coordination, resulting in difficulty keeping up with rapidly-changing physical directions.

The inability to grasp abstract concepts translates to more practical situations.

Financial Planning: Due to the combination of the inability to grasp the concept of money and poor long term memory, financial planning is particularly challenging for people with dyscalculia. The actual value of products means very little. People with dyscalculia can also struggle with purchasing the correct quantities. For example, when buying food at the supermarket, often far too much or too little is bought. When change is given in shops, few people with dyscalculia are able to correctly calculate how much money they have and how much they should have been given back. As a result of all of this, many people with dyscalculia are consistently overdrawn, and rely heavily on others for help.

Currency: Following on from the inability to grasp the concept of money, foreign currency is particularly difficult to comprehend, especially as exchange rates are often changing, and calculations are often involved when trying to convert one currency to another.

Temperature: Temperature is meaningless when told in numbers, especially when both Celsius and Fahrenheit are used.

Traveling: Few people with dyscalculia learn to drive as driving is heavily reliant upon numbers (speed limits, petrol gauge, distances, etc.). This means many must rely upon buses and trains for transport. Getting the right bus/train at the right time, and on the correct platform, are huge problems because each involves the use of numbers and time.

Some Personas With Use Case that Address Key Challenges

Booking a Train Ticket Online

Scenario A "Jenny" is a person with dyscalculia. She is a mother with two young children. She is trying to book train tickets online for herself and her children. The train journey involves one change where she must walk to a different platform. She must also ensure her first train arrives at the change destination with enough time for her to find the correct platform before the train sets off for the second part of her journey. She needs to be able to book the tickets for the correct time, and with the appropriate rail card, to be able to qualify for discounts. She also needs to be able to remember her password for her bank's security system so she can purchase the tickets. This password is made up of a combination of letters and numbers to fulfill the bank's 'secure-password' criteria.

Booking a train ticket online
Step	Challenges
Tick box for 'return'.	no challenges
Type in from and to destinations.	no challenges
Select date and time for outbound & return journeys.	This step is particularly difficult as it requires the entry of a date and a time for travel. People with dyscalculia have a limited ability to grasp the concept of time. Therefore, they may struggle to work out when their train journey is, and also how far away the date and time of their journey is from the current date and time.
Select number of adult & child passengers.	This step may prove difficult as dyscalculia can reduce a person's ability to count. However, if the numbers are not too high and the counting begins at 1, usually this is achievable.
Tick box for rail cards.	no challenges
Select rail-card type and number that apply for this journey.	This step again involves counting. However, as above, if the numbers aren't too high this shouldn't prove too difficult.
Select continue.	no challenges
Tick box for outward & return journeys. (Details to look at: time, price, class & single/return.)	In this step, the only challenge is the selection of the time of the journey. As mentioned above, people with dyscalculia struggle with the concept of time. Therefore, they may be liable to selecting a return journey that occurs before the outward journey. Fortunately, most if not all online train-ticket applications will not allow the transaction to proceed if this is the case. The error will be flagged in red.
Select 'buy now'.	no challenges
Tick box to reserve seat and, if so, select seating preferences - optional.	no challenges
Tick box to collect tickets from self-service ticket machine and select station or tick box to have tickets sent by post.	This is not directly an issue at the point of purchase. However, collecting tickets from a self-service ticket machine can be very difficult for people with dyscalculia. The ticket-collection reference number used to validate the purchase is made up of an entirely random mix of numbers; and upper & lower case letters. It would be almost impossible to commit this reference number to memory, or to find a pattern in it. Therefore, it must copied out, which gives rise to sequencing issues resulting in the numbers being inputted in the wrong order. The whole process could take a very long time.
Select 'continue'.	no challenges
Tick box 'new user'.	no challenges
Type in personal details (name, address, email, etc.).	no challenges
Tick box payment card type (Visa, MasterCard, etc.).	no challenges
Enter card details (number, expiration date, name, security code).	Although this step does involve numbers, it does not require any manipulation of numbers, such as addition, subtraction, etc.. Therefore, the act of typing the numbers from the card into the website should be achievable. However, some people may struggle with sequencing and end up typing the numbers out of order.
Type in post code and tick box 'find billing address'.	no challenges
Tick box to agree to terms and conditions and select 'buy now'.	no challenges
Enter payment card secure bank password.	This step is likely to prove most difficult as it requires the use of long-term memory (LTM), which may be fairly limited in people with dyscalculia. Also, the customer is required to enter a password out of its usual order. For example, the customer may be asked to enter the 3rd, 5th, and 7th characters in the password. As people with dyscalculia struggle with the concept of numbers and sequences, this step may be achievable only by having the password written down in front of them. However, this then reduces the security of their payment method.
Order complete.	no challenges

Using Online Banking to Pay Someone New

Scenario B "Emily" is a high-school student who struggles to understand many of the topics covered in her math, science, and music lessons. She needs to use her online-banking account to transfer some money into a friend's bank account. She hasn't transferred money online to this friend before, so she must set up a new user. This requires using a card reader; and typing in a code that appears on the card reader only for 30 seconds before it changes to increase security.

Using online banking to pay someone new
Step	Challenges
Type in customer number and select 'log in'.	This step is challenging because a person is required to use LTM to type in a customer number. People with dyscalculia typically have poor LTM and difficulty with sequencing. Therefore, again, they may need to have the password written down. This is then a breach of security.
Type in 3 random digits from pin number (e.g. 1st, 3rd, 4th). Type in 3 random characters from password (e.g. 2nd, 5th, 10th).	This requires users to access their LTM to remember the password, and then be able to count up each of the numbers/letters to enter the correct characters out of their normal pattern. Counting is hard for people with dyscalculia, especially when it doesn't begin at 1, which increases the difficulty of these 2 tasks.
Select 'payments and transfers' and then 'go'.	no challenges
Select 'pay someone new'.	no challenges
Enter details of payee and select 'add payee'.	This task does require numbers, so it may be a challenge. However, the numbers need to be copied and not manipulated, which reduces the complexity.
Type in amount to transfer.	Calculating numbers is particularly difficult for people with dyscalculia because their grasp of math concepts and rules is typically quite poor. Therefore, this task could be very challenging.
Follow on-screen instructions to verify new payee. --> Turn on card reader and select function button --> Insert card into card reader --> Type in pin number to card reader --> Type in numbers on the computer screen into the card reader, select 'ok' on the reader --> Type the number that appears on the screen of the card reader into the box online --> Click confirm on the website.	This task is likely to be the most challenging of the transaction due to time constraints that are in place for security reasons. Firstly, users must type their pin number into the card reader, which requires the use of LTM. However, this can be achieved as often people with dyscalculia are able to remember their pin number as a pattern. Then the user must enter the numbers on the computer screen into the card reader. This shouldn't be too difficult because it requires only copying the numbers. The user must then enter numbers, which appear on the screen of the card reader, into a text box on the website. This stage is fairly difficult because the numbers on the card reader change every 30 seconds to increase security. Therefore, the numbers must be typed in fairly quickly. Also, many people with dyscalculia struggle to understand the concept of time. Therefore, they may find it difficult to work out quite how quickly they must enter the numbers before they change.
Payment complete.	no challenges

Changing Payment Details for an Online Supermarket Shop

Scenario C "George" is an elderly gentleman who doesn't like to leave his house, does his supermarket shopping online once a week, and gets it delivered to his door. His bank details are stored on the shopping website so he doesn't have to keep typing them in. However, he has just been sent a new bank card because his old one has expired. Thus, he must re-enter all the details necessary to complete his shop.

Changing the payment details for an online supermarket shop.
Step	Challenges
Select 'food and drink' and then 'buy groceries'.	no challenges
Log in with user name and password.	no challenges
Delete old payment card.	no challenges
Select 'add payment card',	no challenges
Type in the card details	This task should be easily achievable because it does not require any manipulation of the numbers. Also, the numbers do not need to be remembered because they are printed on the card. However, people with dyscalculia struggle with sequencing, and therefore may be liable to typing the numbers out of the correct order.
Tick box 'make this my preferred payment card'.	no challenges
Select 'save' and then either continue shopping or log out.	no challenges

Online Shopping

Whilst people with dyscalculia may find it relatively simple to set up an online shopping account, it is far harder to complete the actual task of shopping. This stems from the inability to grasp the concept of money, and the amount a product costs, in relation to the amount of money they might have in their bank account. As a result of this, people with dyscalculia frequently find themselves overdrawn. The task of calculating numbers to produce a final figure, which has some meaning to them as opposed to being a collection of random numbers, is a concept they cannot master. This often leads to active avoidance of the task, or strong reliability on others, neither of which is a sustainable solution. Quantities are also an abstract concept. People with dyscalculia often buying far too much or not-nearly enough because it is difficult for them to work out exactly how much they need. Anything that involves weights and measures, e.g. 1 kg of potatoes, is also almost impossible to understand.

How They Use the Web and ICT

There is very little in the way of specific assistive technologies for dyscalculia. One person reports using Smart sum - more research required.

http://www.dyscalculator.com/ is a talking calculator, which is designed for dyscalculia.

How People with Dyscalculia Use Optimized Content and Special Pages

Many people with dyscalculia report they enjoy using the Internet. There are quite a lot of people with dyscalculia using social media and online video. There is little if any optimized content available for dyscalculia. The scenarios give examples of where dyscalculia impacts people using products and services on the Internet.

Characteristics of Content Optimized for This Group

Assistive Technology Devices for Students Struggling in Mathematics from the Georgia Department of Education

There is further research needed before we are in a position to add descriptions of key features and how it helps users overcome challenges. Very little work has been done on this topic.

Summary of Existing Research and Guidelines

It is widely acknowledged that dyscalculia was first discovered in 1919 by Salomon Henschen, a Swedish neurologist who found that it was possible for a person of high general intelligence to have impaired mathematical abilities. At the time, it was known as 'number blindness'. The term 'dyscalculia' was later coined by Dr. Josef Gerstman in the 1940s. When compared with dyslexia and other similar learning disabilities, dyscalculia receives relatively little recognition. There is still limited awareness of its existence.

Although there are many classifications of dyscalculia, it can be broken down into 3 sections; developmental dyscalculia (inherited/acquired during prenatal or early developmental period); post-lesion dyscalculia (acquired during an incident of traumatic brain injury affecting specific areas of the brain); and pseudo-dyscalculia (a result of inadequate instruction).

Formal definition: The Department for Education Skills (DfES) defines dyscalculia as: "A condition that affects the ability to acquire arithmetical skills. Dyscalculic learners may have difficulty understanding simple number concepts; lack an intuitive grasp of numbers; and have problems learning number facts and procedures. Even if they produce a correct answer or use a correct method, they may do so mechanically and without confidence."

Etiology

Adult neuropsychological and neuroimaging research points to the intraparietal sulcus as a key region for the representation and processing of numerical magnitude [[Price-1]]. This raises the possibility of a parietal dysfunction as a root cause of dyscalculia [[Price-1]]. The following two studies support this research.

Virtual Dyscalculia Induced by Parietal-Lobe TMS Impairs Automatic Magnitude Processing

UCL scientists state that dyscalculia is a result of a malformation in the right-parietal lobe in the brain. However, the underlying dysfunction is relatively unknown (c.07). The study involved using neuronavigated transcranial magnetic stimulation (TMS) to stimulate the brain and cause dyscalculia, only for a few hundred milliseconds, in typical individuals. The subjects then completed math tasks whilst under stimulation, and produced dyscalculia-like behavior. However, when the left-parietal lobe was stimulated under TMS, this behavior was not observed. Therefore, it can be reasonably assumed there is a causal relationship between defects in the right-parietal lobe and dyscalculia. [[Cohen-Kadosh-1]]

The above research is supported by the following research study: Impaired parietal magnitude processing in developmental dyscalculia. This study was conducted by Gavin R. Price, Ian Holloway, Pekka Räsänen, Manu Vesterinen and Daniel Ansari. It shows that, in children with developmental dyscalculia, the right-intraparietal sulcus is not modulated in response to numerical processing demands to the same degree as in typically-developing children. This suggests a causal relationship between impairment of parietal-magnitude systems and developmental dyscalculia. [[Price-1]]

Research by Shalev, et. al. suggests some families have a genetic predisposition to dyscalculia, resulting in prevalence 10x higher than in the general population. [[Shalev-2]] Although dyscalculia cannot be cured, it is hoped early detection and remedial teaching can go a long way to reducing the effects of dyscalculia on the individual.

Comorbidity

High comorbidity with ADHA (estimates range between 15-26%) and dyslexia (estimates range between 17-64%) [[Wilson-1]]. There is strong evidence to suggest Turners Syndrome and Gerstmann's Syndrome are associated with dyscalculia. [[Bruandet-1]]

Guidelines

Although there are no specific guidelines produced by a governing body, there are several ways to help individuals with dyscalculia improve their mathematical abilities.

study sheets/summary sheets/outlines of most important facts;
supplementary aids (vocabulary, multiplication cards, etc.);
visual demonstrations;
instructions/directions given in different channels (written, spoken, demonstration);
visual or multi-sensory materials;
mnemonic aids/devices.

Some more-useful guidelines regarding dyscalculia, specifically for school children, are available from Leeds City Council (PDF): Guidelines for Specific Learning Difficulties in Maths/Dyscalculia.

Dyscalculia is still a relatively-unknown disability with many of those affected by it not being diagnosed until later in life. Often, with children in schools especially, those affected are thought to be stupid or lazy because many people are unaware of dyscalculia's existence. This is analogous to the treatment of people with dyslexia.

Potentials and Possibilities

Add ideas for filling gaps.

Prevalence

Studies conducted by Gross-Tsur, Manor and Shalev in 1996 suggest that 6.5% of the population have dyscalculia. Conflicting research done by Lewis, Hitch and Walker in 1994 suggests that 1.3% of the population have dyscalculia, while 2.3% have dyscalculia and dyslexia. This puts the world population of people with dyscalculia at 3.6%. (8)

5-6% in school age children. [[Shalev-1]]

This gives the rough estimate that between 3½ and 6½% of the world population is affected by dyscalculia. However, no international study has been done on how common it is.

Studies show the presentation of dyscalculia in males and females is roughly equal. Neither gender appears to have a greater predisposition than the other. [[Shalev-1]]

References to Research

(8) www.dyscalculiaforum.com

(11) Clare Trott http://publications.lboro.ac.uk/publications/all/collated/mact2.html.

Research on Cognitive Function

This section aims to provide:

a basis for consistent use of terms within our documents;
a basis / background for making tags that can be used in meta data or functional-accessibility approach
a useful resource

Note: We have taken terms and concepts from across the work we are doing on disability and cognitive function. Where more than one term exists for what seems to be a very similar function, we have chosen one term, but brought others for reference. We have also reviewed the Caroll taxonomy, but it was focused on educational assessment, and psychometric-based models for human intelligence, and was therefore not fully-relevant (for example: knowledge categories). When quoting a Caroll category, we have tried to put the mnemonic after the term such as (RG) or (I).

Here are the cognitive functions that we have identified so far. They are not complete, and not yet in a taxonomy form.

Reasoning and Executive Functions

Executive functions (also known as cognitive control and supervisory-attentional system) is an umbrella term for the management of cognitive processes such as reasoning and problem solving (goal-focused reasoning) as described below. Executive function also includes:

emotional control and self-monitoring
shift ( also called task flexibility)
initiation
planning/organization
execution

Executive function also relies upon or includes: working memory, other memory (short, long), attention, abstraction, associations, as described below.

In making a decision or conclusion, we may use:

Fluid (logical) reasoning;
Attitudes and experience from or guiding Crystallized intelligence;
An Affective component involving a person’s emotions (such as fear) and identity (sense of self).
Behavioral (or cognitive) component involving memory, such as long-term autobiographical memory.

Reasoning

Fluid reasoning is the capacity to think logically and solve problems in novel situations, independent of acquired knowledge [Fluid_and_crystallized_intelligence] Fluid intelligence may involve both the dorsolateral prefrontal cortex and the anterior cingulate cortex.

Types of fluid reasoning are:

Deductive Reasoning (RG) (sometimes called General or Sequential or hypothetico-deductive reasoning). It is the ability to start with stated assertions (rules, premises, or conditions), and engage in one or more steps leading to a solution.
Inductive Reasoning (Induction (I) Reasoning from specific cases or observations to general rules or to broad generalizations. Often requires the ability to combine separate pieces of information in the formation of inferences, rules, hypotheses, or conclusions.
Mathematical Intelligence (also called Quantitative Reasoning (RQ) depends upon ability to inductively (I) and/or deductively (RG) reason with concepts involving mathematical relations and properties.
Piagetian Reasoning (PR): reasoning via seriation (organizing material into an orderly series that facilitates understanding of relationships between events), conservation (awareness that physical quantities do not change in amount when altered in appearance), and classification.

A related idea is Speed of Reasoning (RE): Speed or fluency in performing reasoning tasks [http://www-personal.umich.edu/~itm/688/wk6/CHC%20Definitions.pdf]

Crystallized Intelligence (sometimes called Comprehension Knowledge), is the ability to use skills, knowledge, and experience. It does not equate to memory, but it does rely on accessing information from long-term memory. Crystallized intelligence is one’s lifetime of intellectual achievement, as demonstrated largely through one's vocabulary and general knowledge. [http://en.wikipedia.org/wiki/Fluid_and_crystallized_intelligence</cite> Crystallized Intelligence involves storage and usage of long-term memories, such as by the hippocampus.

We have included the dependent aspects in the sections on memory and language [ http://www-personal.umich.edu/~itm/688/wk6/CHC%20Definitions.pdf]

Attention

Reasoning and executive functions require attention. Types of attention are the following.

Selective attention refers to the ability to attend to some stimuli while disregarding others irrelevant to the task at hand. [http://www.ncbi.nlm.nih.gov/books/NBK3885/]
Divided attention tasks require the processing of two or more sources of information, or the performance of two or more tasks at the same time. (Divided attention has usually been associated with significant age-related declines in performance, particularly when tasks are complex.) [5]. The cost of dividing attention is assessed by comparing performance under dual-task conditions to performance when the tasks are performed separately. [http://www.ncbi.nlm.nih.gov/books/NBK3885/]
Sustained attention refers to the ability to maintain concentration on a task over an extended period. [http://www.ncbi.nlm.nih.gov/books/NBK3885/]

Abstraction

Types of abstraction include:

essentialism
object recognition - Abstraction is part of visual comprehension
face recognition (seems to be separate from object recognition)
facial patterns (such as an angry face)
linguistical abstractions (such as relations between syntax, semantics, and pragmatics.)
quantities
numerical concepts
abstract context of time
spatial orientation, directions, layout of things.
mechanical abstractions
musical abstractions
behavioral and social abstractions –
- norms, etc
- social cues
- other behavioral:

Memory

People talk about types of memories are often talking about different categories of types of memory. Any memory-based events can be described in all these categories. For example: an event may cause a sensory experience to go into long-term memory implicitly. Here are the types we have identified:

durationbased: working, long term, short term, and possibly intermediary
context based: emotional, procedural, sensory (tactile, smell, psychomotor, kinesthetic, olfactory, auditory, visual, visuo-spatial, spatial, musical, and prospective memory.
awareness level: implicit and explicit

Duration Based

Working memory involves mentally manipulating — is the system that actively holds multiple pieces of transitory information in the mind, where they can be manipulated. [1] Baddeley and Hitch feel it is executive and attention control of short-term memory, but others point out that long term memory can also be involved in working memory.
Short-term memory (also called active or primary memory) typically lasts seconds, such as remembering the phone number while you find a pen and write it down. Subtypes are Verbal, Visual, and Spatial. Four different units in short-term memory are probably average. Capacity of short-term memory is often called memory span.
Long-term memory (also called reference memory, long-term storage and retrieval (Glr),TSR, Glm), the ability to store and consolidate new information in memory and later fluently retrieve stored information. Broad retrieval ability (G) is a related idea.

Context Based

Episodic memory (autobiographical – time, self)
Semantic memory (factual)
Visual memory
Visuo-spatial memory
Spatial memory
Musical memory
Auditory memory: Memory for sound patterns (UM)
Procedural memory: Memory for performance of particular types of action such as walking.
Prospective memory: Much of what we have to remember in everyday life involves prospective memory — remembering to do things in the future, such as keep appointments, return a book to the library, or pay bills on time. [http://www.ncbi.nlm.nih.gov/books/NBK3885/]
Emotional memories: can be both declarative- and procedural-memory processes.

Awareness Based

Implicit memory: (Can be called non-declarative memory) is built or used without conscious awareness. In contrast with...
Explicit memory: (Can be called declarative memory) the intentional use of memory such as remembering the time of an appointment or studying for an exam.

Also, memories can be stored and recalled as Associative Memory (AM), Meaningful memory(MM), Free-recall memory (M6),

Language

Speak, write, read, or understand speech and/or language.

Spoken Languages

The basic skills for spoken languages seem to be speech perception. Speech perception is when sounds of language are heard, interpreted, and understood. This depends upon:

Auditory Discrimination (Note: not loss of hearing, but identification and differentiation of sounds, also called General sound discrimination (U3)
Temporal Tracking (UK)
Listening Ability (LS)
Naming skills (N)
Related memory such as Working Memory, auditory memory - (Memory for sound patterns)
Morphosyntax: The system of the internal structure of words (morphology) and the way in which words are put together to form phrases and sentences (syntax).
Understanding figural language, including a simile (a comparison of two things, such as “His cheeks were like roses”; a metaphor; onomatopoeia (a word designed to be an imitation of a sound such as “Bark! Bark!”); personification (attribution of a personal nature to inanimate objects); an oxymoron (opposite or contradictory terms are used together for emphasis, such as “organized chaos”); a paradox;a hyperbole (an extreme exaggeration, such as “I was so upset I nearly died”); allusion; or idiom, such as "You should keep your eye out for him"); and puns.

Spoken language also requires an ability to produce voice

Sign Language

Sign language, without spoken language, probably requires a slightly-different set of skills, such as:

Visual Recognition Skills
Non-vocal Naming - Association of sign and concept
Phoneme Processing and Phonetic coding (PC)
Related memory, such as Working Memory, Visual memory, Memory for patterns
Morphosyntax: The system of the internal structure of words (morphology) and the way in which words are put together to form phrases and sentences (syntax).
Understanding figural language.

Literacy

Beyond basic language, literacy typically requires:

Visual Recognition (see below)
Visual memory (not affected in Intellectual Disability)
Phoneme Processing and Phonetic coding (PC)
Cross-modal Association of sign and concept

Note that many people with dyslexia achieve literacy without many of these functions, or with impaired functioning.

Perception

Visual Recognition (Also called visual perception)

The visual system automatically groups elements into patterns: Proximity, Similarity, Closure, Symmetry, Common Fate (i.e., common motion), and Continuity (Gestalt psychology).

Functions include:

object recognition
face recognition (seems to be a different process from object recognition [Face and object recognition ((Alex Huk. (1999) "Object and Face Recognition: Lecture Notes." pp. 5]
Pattern Recognition

Other Perception

Auditory perception (see Speech perception above for further classifications), Motor, Tactile, Psychomotor, Kinesthetic (body position, weight, or movement), Olfactory and sensory perception.

Speed

Processing speed affect all functions above. See Caroll. A related concept is fluency

Knowledge

Types of knowledge that might be required for use of Web content include:

knowledge of culture
base Language knowledge, including:
lexical (UL)
jargon (subject matter)
Web jargon and technology
Web and technology usages and risks
metaphors and idioms
icons and symbols
mathematical knowledge
mechanical Knowledge (MK)
knowledge of behaviors
design metaphor – look
design functions

Not (Yet) Fully Addressed:

consciousness
identity
emotions (such as fear), moods, and motivations
libido and sexual function
creative thought
personality
judgment and self-monitoring
initiative
inhibition

Note that these are in our mandate. For example: Dementia with Lewy bodies affects the cerebrum, where small round lumps of proteins build up and can cause fluctuations of consciousness, as well as hallucinations, delusions (firmly held beliefs in things that are not real), and false ideas (such as with paranoia).

Areas of the Brain

This section summaries functions of different areas of the brain. See http://www.md-health.com/Parts-Of-The-Brain-And-Function.html and http://www.enchantedlearning.com/subjects/anatomy/brain/Structure.shtml.

Frontal Lobe

reasoning and problem solving
initiative, inhibition, and behavior
abstractions
attention
creative thought
some emotion
reflection
judgment
coordination of movements
generalized and mass movements
skilled movements and some motor skills
libido (sexual urges)

Occipital Lobe

vision
Broca's Area controls facial neurons as well as understanding of speech and language.

Parietal Lobe

tactile sensation
appreciation of form through touch (stereognosis)
response to internal stimuli (proprioception)
sensory combination and comprehension
some language and reading functions
some visual functions

Temporal Lobe

some hearing
memory, including auditory memories and visual memories
music
some behavior and emotions, such as fear
sense of identity
Wernicke's Area- This portion of the temporal lobe is formed around the auditory cortex. Formulate or understand speech.

Limbic System

The limbic system contains glands, which help relay emotions.

Amygdala: The amygdala helps the body respond to emotions, memories and fear.
Hippocampus: Used for explicit memory, specifically converting temporary memories into permanent memories, which can be stored within the brain. The hippocampus also helps people analyze and remember spatial relationships, enabling accurate movements.
Hypothalamus: mood, thirst, hunger, and temperature.
Thalamus: attention span, sensing pain, and tracking of sensations the body is feeling.

Corpus Callosum

communication between the left and the right sides of the brain

Cerebellum

balance and posture
cardiac, respiratory, and vasomotor centers

Brain Stem

Motor and sensory pathway to body and face
Vital centers: cardiac, respiratory, vasomotor

Pituitary Gland

hormonal body processes
physical maturation
growth (height and form)
sexual maturation
sexual functioning

Sources on Cognitive Functions

1. Educational taxonomies, such as Carol for Cyristalised resing, includes:

Language Development
Lexical Knowledge (VL)
Listening Ability(LS)
General (verbal) Information (K0)
Range of general stored knowledge (primarily verbal)
Information about Culture (K2)
Range of stored general cultural knowledge (e.g., music, art)
Communication Ability (CM)
Oral Production and Fluency (OP)
Grammatical Sensitivity (MY)
Morphology and sentences (syntax)
Foreign Language Proficiency (KL)
Foreign Language Aptitude (LA)

2. Inappropriate behavior is common with Frontotemporal dementia - impaired social interaction.

Affected in: Alzheimer’s disease, Aphasias, Advanced age, dyslexia, emotional disabilities such as Schizophrenia and PTSD

4. Expressive aphasia left inferior frontal cortex. These people are described with having severe syntactical deficits, which means they have extreme difficulty in forming sentences correctly. Hessler, Dorte; Jonkers, Bastiaanse (December 2010). "The influence of phonetic dimensions on aphasic speech perception". Clinical Linguistics and Phonetics. 12 24: 980–996.

5. Receptive aphasia - left temproparietal lobe. People with Receptive Aphasic mostly suffer from lexical-semantic difficulties, but also have difficulties in comprehension tasks. The effect of receptive aphasia on understanding is much more severe. Hessler, Dorte; Jonkers, Bastiaanse (December 2010). "The influence of phonetic dimensions on aphasic speech perception". Clinical Linguistics and Phonetics. 12 24: 980–996.

Anarthria: Loss of the motor ability that enables speech. Complete loss of the ability to vocalize words as a result of an injury to the part of the brain responsible for controlling the larynx.

Aphonia: The inability to produce voice.

Alalia: A delay in the development or use of the mechanisms that produce speech.

Dyslalia: Difficulties in talking due to structural defects in speech organs.

Developmental verbal dyspraxia: Motor speech disorder involving impairments in the motor control of speech production.

6. Carol tends to have abilites as the main category with memory and sensitivity, such as tactile sensitivity (other than psychomotor abilities, which have subcategories of static strength (P3), multi-limb coordination (P6), finger dexterity (P2), manual dexterity (P1), arm-hand steadiness (P7), sontrol precision (P8), aiming (A1), gross-body equilibrium (P4)

7. Carol brings Processing speed (Gs), such as cognitive processing speed (Gs), broad-cognitive speediness (Gs), perceptual speed (P), rate-of-test-taking (R9), number facility (N), speed of reasoning (RE), reading speed (RS), writing speed (WS), reaction and decision Speed (Gt), correct decision speed (CDS), processing speed, (RT) decision speed (such as simple-reaction time) (R1), choice reaction time (R2), semantic processing speed (R4), mental-comparison speed (R7), inspection time (IT)

8. Carol brings Ideational Fluency (FI), Associational Fluency (FA), Expressional Fluency (FE), Word Fluency (FW), Figural Fluency (FF), Figural Flexibility (FX), Sensitivity to Problems (SP), Originality/Creativity Fluency (FO), Learning Abilities (L1), Naming Facility (N)

Introduction

Importance of This Document

Assumptions

Comments

Summary of User Groups and Cognitive Function

Research on User Groups

Dyslexia

Cognitive Functions

Auditory Discrimination

Visual Recognition Skills

Phoneme Processing

Cross-modal Association

Visual Recognition Skills

Working Memory

Symptoms

Challenges

Memory

Automatizing Skills

Information Processing.

Communication Skills

Literacy

Organization, Sequencing

Navigation

Lack of Awareness

Visual Stress

Coping Strategies

Effects of Stress

Scenarios and User Stories

Scenario: Online Research

Scenario: Finding Out About a Change Event in an Email

Scenario: Using a Electronic Interface

Scenario: Using a Phone Menu

How They Use The Web and ICT

Characteristics of Content Optimized For This Group

Specific Technologies

Summary of Existing Research and Guidelines

Summary/Exerts of The British Dyslexia Association Guidelines and Dyslexia Style Guide

Dyslexia-Friendly Text

Media

Headings and Emphasis

Layout

Writing Style

Increasing Accessibility

Checking Readability

Accessible Formats

Preparing a Document for Text-Reading Software

Website Design

See Also

Other Guidelines

Extent To Which Current Needs Are Met

Potentials and Possibilities

Prevalence

Sources and References

References to Research

Non-verbal - Severe Speech and Language impairments

Cognitive Functions

Symptoms

Challenges

How Symptoms result in Challenges for Young People who are Non-Verbal

No Support

Non-Interoperability

Costs of Low-Tech AAC

Costs of High-Tech AAC

Costs of Lack of AAC

Scenarios and User Stories

Young Non-Verbal Woman

How They Use the Web and ICT

Characteristics of Content Optimized for This Group

Specific Technologies

Extent To Which Current Needs Are Met

Potentials and Possibilities

Prevalence

References to Research

Glossary

Communication Disorders

Cognitive Functions

Intellectual Disability

Cognitive functions

Overview

Auditory Discrimination