Cognitive Accessibility User Research

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.

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).

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]

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.

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.

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.

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.

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.

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.

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.

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.

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.

Professional Man with Aphasia

Mr C was a highly skilled accountant before he suffered a stroke, he read widely and enjoyed using technology for both his work and leisure activities. After a severe left sided brain haemorrhage he not only could not speak clearly and had difficulty understanding conversation, but he also found that he could not read or write in a recognizable way. He found it hard to concentrate and when trying to use the Internet he did not have the skills to search for things of interest let alone read the content of the web pages. He was extremely frustrated, found himself breaking down. It was extremely distressing for his family. Slowly words returned and reading skills improved but he found the clutter on the screen exasperating and often failed to select the correct link or menu item. As he progressed in his rehabilitation, he was able to read slowly and made limited use of text to speech and increased font sizing. However, he tired easily, complained of eye strain and would often give up if he could not find something he was searching for. He could not cope with CAPTCHA technology, found form filling difficult and would often buy the wrong items on Amazon by accident. However, with support and using simple technologies to de-clutter web sites, so that the text was clear without advertisements and excessive imagery Mr. C continued to take up the challenge of reading from the screen and his skills slowly improved. Eventually he was able to make use of social networks with friends who understood his difficulties and enjoyed asynchronous communication where he did not have to answer immediately and could take his time reading and composing messages.

More References

Kitching, J. (1990). Patient information leafl ets: The state of the art. Journal of the Royal Society of Medicine , 83 , 298 – 300. Tarleton, B.,(‎2008) Finding the Right Help - University of Bristol http://www.bristol.ac.uk/wtwpn/resources/finding-the-right-help-report.pdf (accessed 27th June 2014) [Kitching-1]

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-1] may or may not be tied directly to a communication disorder. An individual may have high cognitive functioning and still be unable to communicate.

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:

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.

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.

Description of Alzheimer's

Alzheimer's disease (62% of those with dementia): A physical disease caused by changes in the structure of the brain and a shortage of important chemicals that help with the transmission of messages. In short, Alzheimer's is a brain disease that causes a slow decline in memory, thinking and reasoning skills.

Statistics are from 2013 UK Study. Need to map with WHO and others.

Description of Less Common (Non-Alzheimer's)

Set of non-Alzheimer's Dementia diseases:

• Vascular Dementia (17%): Caused by problems in the supply of blood to the brain, commonly caused by a stroke or a series of small strokes.

• Mixed Dementia (10%): A type of dementia where a person has a diagnosis of both Alzheimer's disease and vascular dementia.

• Dementia with Lewy bodies (4%): One of the less-common forms of dementia, it is caused by irregularities in brain cells, leading to symptoms similar to Alzheimer's disease, and Parkinson's disease.

• Rarer causes of Dementia (3%): There are many rarer causes of diseases and syndromes that can lead to dementia or dementia-like symptoms, including Corticobasal degeneration and Creutzfeldt-Jakob disease.

• Fronto-temporal Dementia (2%): Rare when all ages are taken into account, but relatively common in people under 65, it is a physical disease that affects the brain.

Statistics are from 2013 UK Study. Need to map with WHO and others.

Research Sources

These resources are relevant to this section. For our next draft, components of these articles will be incorporated into this section where applicable.

1. [Trewin-1] (Contributed by Katherine Deibel)

Cognitive-Function Decline Due to Dementia

Overview: The parts of the brain and cognitive functions affected depend upon the type of dementia.

Research Sources

These resources are relevant to this section. For our next draft, components of these articles will be incorporated into this section where applicable.

1.  To be determined

Common Symptoms of Cognitive Decline Due to Both MCI and Dementia

1. Difficulty remembering information (tends to fluctuate as the day progresses, and decline over long periods of time).
2. Difficulty with organizing thoughts.
3. Difficulty working within time limits.
4. Visual processing difficulties, which can affect the ability to recognize places.

Symptoms of Cognitive Decline Due to MCI

1. Memory: Sometimes forget names or appointments, but then remember them later.
2. Problem Solving: May make occasional errors when balancing a checkbook.
3. Completing Tasks: May need occasional help to use the settings on a microwave or to record a television show.
4. Confusion w/ Time or Place: May get confused about the day of the week, but then figures it out later.
5. Visual/Spatial/Temporal Understanding: May have vision changes related to cataracts, low vision, and/or color/contrast perception. May have some hearing or speech loss. May have diminished motor ability and acuity. May want/need to combine "Confusion w/ Time or Place" and "Visual/Spatial/Temporal Understanding".
6. Conversation: Sometimes have trouble finding the right word.
7. Misplacing Items: May misplace things from time to time, and then need to retrace their steps to find them.
8. Judgment: May make a bad decision once in a while.
9. Withdrawal: May, on occasion, feel weary of work, family, and social obligations.
10. Mood/Personality: May develop very-specific ways of doing things, and therefore may become irritable when a routine is disrupted.

Symptoms of Cognitive Decline Due to Dementia

Typical behaviors exhibited by people with Dementia

1. Repetitive Behavior - Asking the same question over and over again. As well as memory loss, this can be due to the people's feelings of insecurity, or anxiety about their ability to cope.
   1. Repetitive phrases or movements - This can be due to noisy or stressful surroundings; or boredom. It can also be a sign of discomfort, e.g., too hot or cold.
   2. Repetitive actions - Actions, such as repeatedly packing and unpacking a bag, or rearranging chairs in a room, may relate to a former activity.
   3. Repeatedly asking to go home - This can be a sign of anxiety, insecurity, fear, or depression. The concept of 'home' might evoke memories of a time or place of comfort and safety. People may not recognize their present environment as their home, even if it is the place where they live.
   4. Multiple phone calls - Some people with dementia phone their loved ones over and over again, particularly in the middle of the night. They may forget they have already called; or may be insecure or anxious.
2. Restlessness
   1. Pacing up and down - Pacing may indicate a desire to use the toilet, but an inability to say that. Alternatively, pacing may indicate a feeling of frustration, and wanting some fresh air.
   2. Fidgeting - Someone with dementia may fidget constantly.
3. Shouting and Screaming
   1. People may continually call out for someone; shout the same word; or scream or wail over and over again. They could be experiencing difficulties with visual perception or hallucinations.
   2. People with dementia may feel lonely or distressed. If their short term memory is damaged, they may not remember that someone is in the next room, and believe they are alone. They may feel anxious about their failing memory; bored; or stressed by too-much noise and bustle.
4. Lack of inhibition
   1. Some people with dementia may undress in public, having forgotten when and where it is appropriate to remove their clothes.
   2. Apparently-inappropriate sexual behavior may be a result of the physical damage to the part of the brain that allows recognition of acceptable social behaviors.
   3. Some actions, such as lifting a skirt or fiddling with flies, may simply be a sign that the person wants to use the toilet.
   4. The person may behave rudely, for example, by insulting people, by swearing, or by spitting.
5. Night-time Waking
   1. Many people with dementia are restless at night, and find it difficult to sleep. Older people often need less sleep than younger people in any case. Dementia can affect people's body clocks. They may get up in the night, get dressed, or even go outside.
6. Trailing and Checking
   1. Living with dementia makes many people feel extremely insecure and anxious. This can result in constantly following their carers or loved ones around, or calling out to check where they are. A few moments may seem like hours to a person with dementia. They may feel safe only if other people are nearby.
7. Hiding and Losing things
   1. People with dementia sometimes hide things and then forget where they are, or forget they have hidden them at all. The wish to hide things may be due to feelings of insecurity, and a desire to hold on to what little they still have.
8. Suspicion
   1. Some people with dementia can become suspicious. If they have mislaid an object, they may accuse someone of stealing it, or they may imagine that a friendly neighbor is plotting against them. These ideas may be due to failing memory, or an inability to recognize people,
9. Sleeplessness and ‘sundowning'
   1. Many people with dementia, especially in the middle stages, experience periods of increased confusion at dusk, with their disorientation continuing throughout the night. These periods, of what is known as 'sundowning', usually diminish as dementia progresses. (1)

Research Sources

These resources are relevant to this section. For our next draft, components of these articles will be incorporated into this section where applicable.

1. [Nunes-1] (Contributed by Katherine Deibel)
2. [Sato-1] (Contributed by Katherine Deibel)

Challenges

• Remembering steps to complete a task, e.g., "How do I send an email?"
• Overwhelmed by too many functions, complex UIs.
• Copying information correctly.
• Difficulty figuring out new UI metaphors.
• Too many steps to complete a task.
• Advertising prompts added before getting to a web page are confusing.
• Menu systems are difficult to navigate and find the right path.
• 15% of people living with dementia, an estimated 112,500 people (in the UK), have been victims of financial abuse, such as cold calling, scam mail, or mis-selling.
• 62% of carers reported that the person they care for had been approached by cold callers or doorstep-sales people.
• 70% reported that telephone callers routinely targeted the person they care for. Not only have people lost money, but they and their families have also suffered stress, exhaustion, and frustration as a result.
• 76% of people reported having trouble managing their money, with a range of issues highlighted, such as the challenges of bank-security procedures; and a lack of dementia awareness in banks and other financial-services organizations. UK ONLY [Chandaria-1]
• Mood/Personality: Controlling confusion and irritability when changes are made to their routine, environment, or location. Difficulty in feeling safe.

Research Sources

These resources are relevant to this section. For our next draft, components of these articles will be incorporated into this section where applicable.

1. [Trewin-1] (Contributed by Katherine Deibel)
2. [Wockl-1] (Contributed by Katherine Deibel)
3. [Sato-1] (Contributed by Katherine Deibel)

Scenarios

• Struggling to remember recent events, but easily recalling things from the past.
• Finding it hard to follow conversations or programs (on TV, web, video, webcast).
• Forgetting the names of friends or everyday objects.
• Repeating themselves, or losing the thread of what they are saying.
• Problems with thinking and reasoning.
• Feeling anxious, depressed, or angry about forgetfulness.
• Other people starting to comment on their forgetfulness.
• Confused, even when in a familiar environment (in space; and on TV, web, video, webcast).
• A decline in the ability to talk, read or write.

User Stories

Personas

• "I have great difficulty remembering things, working things out, and interpreting things. I use a Dictaphone, which helps considerably. I can't use a normal watch so I've gone digital, but that has its limitations. I can't read very well so I use audio books. I can't count money, but I haven't found a way around that yet, so any suggestions will be gratefully received! So, I've developed strategies to help. These can be very simple but effective if they work. Often, it is the simplest things that get the better of us - things we have done all our lives without a problem. But now, because we can't do them, it is very frustrating." - Extract from a speech by Ann Johnson at the Uk Dementia Congress, November, 2010.

Research Sources

These resources are relevant to this section. For our next draft, components of these articles will be incorporated into this section where applicable.

1.  To be determined

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To do: Add table.

Research Sources

These resources are relevant to this section. For our next draft, components of these articles will be incorporated into this section where applicable.

1.  To be determined

Summary of Existing Research and Guidelines - Research Sources

Key features from Phiriyapkanon:

1. Reduction of complexity: Factions that are rarely used, or are not necessary, should be removed.
2. Clear structure of task: The starting points of tasks and every step should be easily recognized and understood.
3. Consistency of information: Avoid contradictions and inconsistencies of information arraignment.
4. Rapid and direct feedback: Applications should continuously provide easily-recognizable feedback of success or failure with every action.

They also should minimize errors; and provide on-screen help and high recover-ability. [Phiriyapokanon-1].

K Dobsz et. al. recommends:

1. strong contrast of images with content;
2. simple and large graphics;
3. sound conformation of accepted and rejected operations;
4. automatic-voicing reading tasks (instructions).

[Dobsz-1]

Key features from other guidelines:

1. To help with difficulties in completing complex tasks, waiting until the elder completes one task before proceeding to the next step.
2. Place tasks in step-by-step order.

Balance this because too-many steps can give a feeling of getting lost.

1. One has to be consistent in naming steps, such as naming all steps beginning with a verb (such as "press the button").
2. Orientation impairments cause elderly to unlearn how to find their way in new surroundings. Therefore:
   1. Menus and usability interfaces need to be simplified to minimize the amount of information that needs to be memorized.
   2. An application should work independent of other applications.
   3. The screen should not have distracting elements (wallpaper, buttons etc.).
3. Information should be broken down into discreet chunks that the elderly can absorb.
4. Content and information need to be consistent.
5. Avoid stress that will further impair cognitive function.

[Muskens-1]

Key features for using tablets for the elderly from Dahn et. al.:

1. The user interface should use widgets or large buttons rather then standard apps. Moving between screens should be possible using tabs or buttons, and not just gestures.
2. Dedicated user interfaces often fall short of user requirements. Instead, populate the tablet with standard apps that have simple interfaces.
3. Offer a PC-like mode with "file explorer" and familiar PC-interface features.
4. Supply a printed manual.
5. Privacy policies should be transparent to build trust.
6. Supply a scaffolding approach to help and support, but allow flexible-entry points.

[Dahn-1]

1. Older Equipment and Software: Some people who are aging or have dementia will be using older browsers and devices that might not be as capable or fault tolerant as current technologies; or may be missing some of the customized and interactive content provided by newer technologies.

Research Sources

These resources are relevant to this section. For our next draft, components of these articles will be incorporated into this section where applicable.

1. [Sato-1] (Contributed by Katherine Deibel)

Use of Language and Communication for Dementias

[#LANG]

• Avoid use of voice recognition or spoken commands from the end-user.
• In either spoken or written information, use simple words, avoiding abstract, unfamiliar vocabulary.
• In either spoken or written information, use simple sentences with just one idea per sentence. Avoid long sentences with embedded ideas.
• Avoid pronouns or other forms of language that rely upon people having to recall information which they have just read or heard.
• Support writing with clear visual images to account for potential vision deficits that have an impact on reading ability.

Research Sources

These resources are relevant to this section. For our next draft, components of these articles will be incorporated into this section where applicable.

1.  To be determined

{Section}

Add ideas for filling gaps.

1. Memory:
   1. enhanced use of color
      1. 1.4.1 - Use of Color (A) requires that color is not used as the only visual means of conveying information, indicating an action, prompting a response, or distinguishing a visual element. Perceivable
   2. Context and Orientation
      1. 2.4.3 - Focus Order (A) says "components receive focus in an order that preserves meaning and operability". Operable
      2. 2.4.7 - Focus Visible (AA) requires an ability for the "keyboard focus indicator (to be) visible". Operable
      3. 2.4.4 - Link Purpose (In Context) (A) requires that the purpose of a link can be determined from the link text alone, or from the link text together with its surrounding context. Operable
      4. 2.4.9 - Link Purpose (Link Only) (AAA) says "a mechanism is available to allow the purpose of each link to be identified from link text alone". Operable
      5. 2.4.7 - Focus Visible (AA) requires a visible keyboard focus indicator that shows which component on the web page has focus. Operable
      6. 2.4.8 - Location (AAA) says "information about the user's location within a set of Web pages is available". Operable
      7. 2.4.2 - Page Title (A) says "web pages have titles that describe topic or purpose". (This is important for search results as the page title is usually displayed first in the listing.) Operable
   3. prompts and cues;
   4. index or table of contents;
   5. support text with redundant visual and auditory elements.
      1. 1.1.1 - Non-text Content (A) says "a text alternative that serves the equivalent purpose" is required. Perceivable
      2. 1.3.1 - Info and Relationships (A) says "information, structure, and relationships" to be made available, for example to text-to-speech software. Perceivable
      3. Software that visually highlights spoken text.
   6. help index
   7. Context Sensitive (support and) Help
      1. 3.1.3 Unusual Words (Level AAA) Understandable
      2. 3.1.4 Abbreviations (Level AAA) Understandable
   8. grouping and symmetry (to leverage visual perception and attention);
   9. intuitive design - ease of interaction (to leverage spatial memory);
      1. 2.1.1 - Keyboard (A) says "the content is operable through a keyboard interface". Operable
      2. 2.1.2 - No Keyboard trap (A) makes sure that keyboard focus "can be moved away from that component using only a keyboard". Operable
      3. 2.1.3 - Keyboard (No Exception) (AAA) says "all functionality of the content is operable through a keyboard interface". Operable
      4. 2.4.1 - Bypass Blocks (A) says "a mechanism is available to bypass blocks of content that are repeated". Operable
      5. 2.4.3 - Focus Order (A) says "components receive focus in an order that preserves meaning and operability". Operable
      6. 2.4.7 - Focus Visible (AA) requires an ability for the "keyboard focus indicator (to be) visible". Operable
      7. 3.3.2 - Labels or Instructions (A) says that labels should be provided "when content requires user input". Understandable
   10. Consistent Navigation
       1. 2.4.5 - Multiple Ways (AA) says "more than one way is available to locate a Web page within a set of Web pages". Operable
   11. consistent identification;
   12. simplified user controls;
   13. error prevention and recovery;
   14. avoid distractions and seizures.
       1. 1.4.2 - Audio Control (A) says "a mechanism is available to pause or stop the audio". Perceivable
       2. 2.2.2 - Pause, Stop, Hide (A) says "a mechanism for the user to pause, stop, or hide" moving or blinking content. Operable
       3. 2.2.4 - Interruptions (AAA) says "interruptions can be postponed or suppressed". Operable
       4. 2.3.1 - Three Flashes or Below Threshold (A) Operable
       5. 2.3.2 Three Flashes (AAA) Operable
2. Problem Solving:
   1. Content Alternatives
      1. 1.1.1 - Non-text Content (A) Perceivable
      2. 1.2.1 - Audio-only and Video-only (Prerecorded) (A) Perceivable
      3. 1.2.2 - Captions (Prerecorded) (A) Perceivable
      4. 1.2.3 - Audio Description or Media Alternative (Prerecorded video) (A) Perceivable
      5. 1.2.4 - Captions (Live) (A) Perceivable
      6. 1.2.5 - Audio Description (Prerecorded video) (AA) Perceivable
      7. 1.2.7 - Extended Audio Description (Prerecorded video) (AAA) Perceivable
      8. 1.2.8 - Media Alternative (Prerecorded) (AAA) Perceivable
      9. 1.2.9 - Audio-only (Live) (AAA) Perceivable
      10. 1.4.7 - Low or No Background Audio (Prerecorded) (AAA) Perceivable
   2. prompts and cues;
   3. logical work flow with redundant text, visual cues, and auditory cues;
   4. grouping and symmetry (to leverage visual perception and attention);
   5. intuitive design - ease of interaction (to leverage spatial memory).
   6. Consistent Navigation
      1. 2.4.5 - Multiple Ways (AA) says "more than one way is available to locate a Web page within a set of Web pages". Operable
   7. consistent identification;
   8. easy user customization;
   9. simplified user controls;
3. Completing Tasks:
   1. prompts and cues;
   2. grouping and symmetry (to leverage visual perception and attention);
   3. intuitive design - ease of interaction (to leverage spatial memory);
   4. easy user customizations.
      1. 1.4.4 - Resize Text (AA) says "text can be resized without assistive technology up to 200 percent without loss of content or functionality". Perceivable
      2. 1.4.8 - Visual Presentation (AAA) includes requirements on text style, text justification, line spacing, line length, and horizontal scrolling. Perceivable
   5. simplified user controls;
   6. error prevention and recovery;
   7. avoid distractions and seizures;
      1. 1.4.2 - Audio Control (A) says "a mechanism is available to pause or stop the audio". Perceivable
      2. 2.2.2 - Pause, Stop, Hide (A) says "a mechanism for the user to pause, stop, or hide" moving or blinking content. Operable
      3. 2.2.4 - Interruptions (AAA) says "interruptions can be postponed or suppressed". Operable
      4. 2.3.1 - Three Flashes or Below Threshold (A) Operable
      5. 2.3.2 Three Flashes (AAA) Operable
4. Confusion w/ Time or Place:
   1. Context and Orientation
      1. 2.4.3 - Focus Order (A) says "components receive focus in an order that preserves meaning and operability". Operable
      2. 2.4.7 - Focus Visible (AA) requires an ability for the "keyboard focus indicator (to be) visible". Operable
      3. 2.4.4 - Link Purpose (In Context) (A) requires that the purpose of a link can be determined from the link text alone, or from the link text together with its surrounding context. Operable
      4. 2.4.9 - Link Purpose (Link Only) (AAA) says "a mechanism is available to allow the purpose of each link to be identified from link text alone". Operable
      5. 2.4.7 - Focus Visible (AA) requires a visible keyboard focus indicator that shows what component on the web page has focus. Operable
      6. 2.4.8 - Location (AAA) says "information about the user's location within a set of Web pages is available". Operable
      7. 2.4.2 - Page Title (A) says "web pages have titles that describe topic or purpose" (this is important for search results as the page title is usually displayed first in the listing). Operable
   2. Identify current state.
   3. Consistent Navigation
      1. 2.4.5 - Multiple Ways (AA) says "more than one way is available to locate a Web page within a set of Web pages". Operable
   4. consistent identification;
   5. simplified user controls;
   6. error prevention and recovery;
   7. Avoid Distractions and Seizures.
      1. 1.4.2 - Audio Control (A) says "a mechanism is available to pause or stop the audio". Perceivable
      2. 2.2.2 - Pause, Stop, Hide (A) says "a mechanism for the user to pause, stop, or hide" moving or blinking content. Operable
      3. 2.2.4 - Interruptions (AAA) says "interruptions can be postponed or suppressed". Operable
      4. 2.3.1 - Three Flashes or Below Threshold (A) Operable
      5. 2.3.2 Three Flashes (AAA) Operable
5. Visual/Spatial/Temporal Understanding: May want/need to combine "Confusion w/ Time or Place" and "Visual/Spatial/Temporal Understanding".
   1. Content Alternatives
      1. 1.1.1 - Non-text Content (A) Perceivable
      2. 1.2.1 - Audio-only and Video-only (Prerecorded) (A) Perceivable
      3. 1.2.2 - Captions (Prerecorded) (A) Perceivable
      4. 1.2.3 - Audio Description or Media Alternative (Prerecorded video) (A) Perceivable
      5. 1.2.4 - Captions (Live) (A) Perceivable
      6. 1.2.5 - Audio Description (Prerecorded video) (AA) Perceivable
      7. 1.2.7 - Extended Audio Description (Prerecorded video) (AAA) Perceivable
      8. 1.2.8 - Media Alternative (Prerecorded) (AAA) Perceivable
      9. 1.2.9 - Audio-only (Live) (AAA) Perceivable
      10. 1.4.7 - Low or No Background Audio (Prerecorded) (AAA) Perceivable
   2. large selection targets;
   3. zoom controls, large fonts.
      1. 1.4.4 - Resize Text (AA) says "text can be resized without assistive technology up to 200 percent without loss of content or functionality". Perceivable
   4. close proximity;
   5. context and orientation.
      1. 2.4.3 - Focus Order (A) says "components receive focus in an order that preserves meaning and operability". Operable
      2. 2.4.7 - Focus Visible (AA) requires an ability for the "keyboard focus indicator (to be) visible". Operable
      3. 2.4.4 - Link Purpose (In Context) (A) requires that the purpose of a link can be determined from the link text alone, or from the link text together with its surrounding context. Operable
      4. 2.4.9 - Link Purpose (Link Only) (AAA) says "a mechanism is available to allow the purpose of each link to be identified from link text alone". Operable
      5. 2.4.7 - Focus Visible (AA) requires a visible keyboard focus indicator that shows what component on the web page has focus. Operable
      6. 2.4.8 - Location (AAA) says "information about the user's location within a set of Web pages is available". Operable
      7. 2.4.2 - Page Title (A) says "web pages have titles that describe topic or purpose". (This is important for search results as the page title is usually displayed first in the listing.) Operable
   6. prompts and cues;
   7. support text with redundant visual and auditory elements;
   8. help index;
   9. context-sensitive help;
   10. plain language;
   11. grouping and symmetry (to leverage visual perception and attention);
   12. intuitive design - ease of interaction (to leverage spatial memory);
   13. consistent navigation.
       1. 2.4.5 - Multiple Ways (AA) says "more than one way is available to locate a Web page within a set of Web pages". Operable
   14. consistent identification;
   15. enhanced use of color and contrast.
       1. 1.4.1 - Use of Color (A) requires that color is not used as the only visual means of conveying information, indicating an action, prompting a response, or distinguishing a visual element. Perceivable
       2. 1.4.3 - Contrast (Minimum) (AA) requires a contrast ratio of at least 4.5:1 for the visual presentation of text and images. Perceivable
       3. 1.4.6 - Contrast (Enhanced) (AAA) requires a higher contrast ratio of at least 7:1 for the visual presentation of text and images. Perceivable
   16. easy user customizations
       1. 1.4.4 - Resize Text (AA) says "text can be resized without assistive technology up to 200 percent without loss of content or functionality". Perceivable
       2. 1.4.8 - Visual Presentation (AAA) includes requirements on text style, text justification, line spacing, line length, and horizontal scrolling. Perceivable
   17. simplified user controls;
   18. error prevention and recovery;
   19. avoid distractions and seizures.
       1. 1.4.2 - Audio Control (A) says "a mechanism is available to pause or stop the audio". Perceivable
       2. 2.2.2 - Pause, Stop, Hide (A) says "a mechanism for the user to pause, stop, or hide" moving or blinking content. Operable
       3. 2.2.4 - Interruptions (AAA) says "interruptions can be postponed or suppressed". Operable
       4. 2.3.1 - Three Flashes or Below Threshold (A) Operable
       5. 2.3.2 Three Flashes (AAA) Operable
6. Conversation:
   1. text;
   2. support text with redundant visual and auditory elements;
   3. simplified user controls.
7. Misplacing Items:
   1. site map;
   2. index or table of contents;
   3. help index;
   4. context-sensitive help;
   5. consistent navigation.
      1. 2.4.5 - Multiple Ways (AA) says "more than one way is available to locate a Web page within a set of Web pages". Operable
   6. consistent identification
8. Judgment:
   1. prompts and cues;
   2. support text with redundant visual and auditory elements;
   3. grouping and symmetry (to leverage visual perception and attention).
9. Withdrawal:
   1. easy user customizations
      1. 1.4.4 - Resize Text (AA) says "text can be resized without assistive technology up to 200 percent without loss of content or functionality". Perceivable
      2. 1.4.8 - Visual Presentation (AAA) includes requirements on text style, text justification, line spacing, line length, and horizontal scrolling. Perceivable
   2. simplified user controls;
   3. error prevention and recovery;
   4. emotional expression (EmotionML).
10. Mood/Personality:
    1. encouragement;
    2. immediate positive feedback;
    3. safety controls;
    4. grouping and symmetry (to leverage visual perception and attention);
    5. consistent navigation.
       1. 2.4.5 - Multiple Ways (AA) says "more than one way is available to locate a Web page within a set of Web pages". Operable
    6. consistent identification;
    7. easy user customizations.
       1. 1.4.4 - Resize Text (AA) says "text can be resized without assistive technology up to 200 percent without loss of content or functionality". Perceivable
       2. 1.4.8 - Visual Presentation (AAA) includes requirements on text style, text justification, line spacing, line length, and horizontal scrolling. Perceivable
    8. simplified user controls;
    9. error prevention and recovery;
    10. emotional expression (EmotionML).

Research Sources

These resources are relevant to this section. For our next draft, components of these articles will be incorporated into this section where applicable.

1.  To be determined

Prevalence of Dementia

• UK (2013 Study)
  • Alzheimer's Society estimates there are 428,000 people in the UK who are living with dementia that haven't been formally diagnosed.
  • Two thirds of people with dementia are women.
  • One in three people over 65 will develop dementia.
  • 40-64 years: 1 in 1,400
  • 65-69 years: 1 in 100
  • 70-79 years: 1 in 25
  • 80+ years: 1 in 6
  • Future Projections: The number of people in the UK with dementia will double in the next 40 years.
    • 800,000 people with dementia in 2012
    • 1,000,000 people with dementia in 2021
    • 1,700,000 people with dementia in 2051

Prevalence of Aging

• World Health Organization: 2012 Study
  • The world population is rapidly aging.
    • Between 2000 and 2050, the proportion of the world's population over 60 years old will double, from about 11% to 22%. The number of people aged 60 years and over is expected to increase from 605 million to 2 billion over the same period.
  • The number of people aged 80 and older will quadruple in the period 2000 to 2050.
    • By 2050, the world will have almost 400 million people aged 80 years or older.
  • By 2050, 80% of older people will live in low- and middle-income countries.
  • The main health burdens for older people are from non-communicable diseases, while the greatest causes of disability are visual impairment, dementia, hearing loss, and osteoarthritis.
  • Older people in low- and middle-income countries carry a greater disease burden than those in the rich world.
  • The need for long-term care is rising.
    • The number of older people, who are no longer able to look after themselves, is forecast to quadruple by 2050 in developing countries.
  • Effective, community-level primary health care for older people is crucial.
  • Supportive, "age-friendly" environments enable older people to live fuller lives, and maximize the contribution they make.
    • Creating "age-friendly" physical and social environments can have a big impact on improving the active participation and independence of older people.
  • Healthy aging starts with healthy behaviors in earlier stages of life.
  • We need to reinvent our assumptions of old age.
    • Society needs to break stereotypes and develop new models of aging for the 21st century. Everyone benefits from communities, workplaces, and societies that encourage active and visible participation of older people.

References on Aging

• World Health Organization: On Aging: [WHO-3].

• W3C Developing Websites for Older People: How WCAG 2.0 Applies: [WAI].

References on Dementia

• UK: Alzheimer's Society: http://www.alzheimers.org.uk/site/index.php.
  • 2013 Study: (Text Only Version) [UKAS-1]
• UK: Dementia Voices: http://dementiavoices.org.uk/.
  • Designing Websites for People with Dementia: [DEEP-1]

References from literature reviews on Dementia and ICT from Peter Cudd

INDIVUI

How Individual Should Digital AT User Interfaces Be for People with Dementia. [Cudd-1]

Abstract. A literature review of papers that have explored digital-technology. user-interface design for people with dementia is reported. Only papers that have employed target user input directly, or from other works, have been included. Twenty four were analyzed. Improvements in reporting of studies are recommended. A case is made for considering the population of people with dementia as so heterogeneous that one design does not suit all. This is illustrated through some case-study reports from people with dementia. Furthermore, it is proposed that, by grouping people into functionally-similar sub-groups, interfaces may be designed for these groups that will collectively establish a sequence of 'stepping stone' interfaces that better address appropriate functioning and maintain self-efficacy. Fundamentally, people living with dementia are unique individuals with unique specific needs. A priori, in life experiences, interests, willingness to learn, environmental factors, and co-morbidities, they are as varied as any of their age peers. One thing they do not share with those peers is the degenerative consequences of the specific dementia they have. The progression of their disease also follows a unique time line, even if the general symptoms (and thus perhaps functional ability) change in a fairly predictable order. In the face of these statements, it might be inferred that it is most likely people with dementia require individual but adaptive (to progression of the disease), bespoke solutions for sustained independent living.

Given the breadth of individuality in people, the effects of dementias, and indeed their progression, it is impossible to view them as a single, homogeneous population in terms of specifying a single user interface. In consequence, rather than simply designing for all people living with dementia, it is suggested that design for populations at stages of functional ability be investigated. Methods that set out to identify shared and bespoke requirements are needed to systematically establish any generalization. Currently, studies on design of digital AT, and indeed other ICT for people living with dementia, need to report much-more detail on: describing their participants; details of user interface features that worked well; and how much and what form carers' help took. More attention also needs to compare strategies and features that work to identify those that are best; or at least best for specific functional ability or tasks.

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

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.

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.

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.

Predominantly Inattentive ADHD - symptoms

Symptoms associated with Predominantly Inattentive ADHD include:

• failing to pay close attention to detail or making careless mistakes;
• having difficulty sustaining attention;
• not appearing to listen;
• struggling to follow instructions to completion;
• difficulty with organization;
• avoiding or disliking tasks requiring a lot of thinking;
• losing things;
• being easily distracted;
• being forgetful in daily activities.

Predominantly Hyperactive-Impulsive ADHD – symptoms

Symptoms associated with Predominantly Hyperactive-Impulsive ADHD include:

• fidgeting with hands or feet or squirming in chairs;
• having difficulty remaining seated;
• running around or climbing excessively (in children), extreme restlessness (in adults);
• difficulty engaging in activities quietly;
• acting as if driven by a motor (adults will often feel inside like they were driven by a motor);
• talking excessively;
• calling out answers before questions have been completed;
• difficulty in waiting or in taking turns;
• interrupting or intruding upon others.

Diagnosis of ADHD

To be diagnosed with ADHD using the above symptoms, a child should exhibit at least 6 of the symptoms. A late-teen or an adult should exhibit at least 5. The ADHD presentation exhibited depends upon the predominance of the symptoms, being: mostly-inattentive symptoms; mostly hyperactive-impulsive symptoms; or a relatively-equal mix of symptom types, resulting in Predominantly Inattentive ADHD, Predominantly Hyperactive-Impulsive ADHD, or Combined ADHD respectively.

ADHD presentations can be subdivided into mild, moderate, or severe depending upon both the number of symptoms exhibited, and the impact the symptoms have on the individual’s daily life. Presentations are not fixed. They can change throughout the lifetime of a person with ADHD, as can the severity of the individual symptoms.

Buying a book online

Scenario A: "Paula" has been diagnosed with ADHD presenting as predominantly inattentive. She is 19 years old, with low self-esteem, and is easily discouraged. Her attention to detail is poor, and her attention span is low. She has a tendency to forget things quickly, and to give up in frustration. She has both younger and older siblings who do not present with ADHD. She does not receive medication.

She is trying to buy a book using an online retailer, for her father, as a birthday present. Paula has never used an online retailer before. She has decided that a book on Indian Cooking would be an appropriate gift. Her father does not read books in electronic format.

Booking train tickets online

Scenario B: "Ian" is 34. He has been diagnosed with ADHD, presenting predominantly Hyperactive-Impulsive. He lives alone. Despite his outward appearance, social exclusion as a child has led to Ian having low self-esteem. Ian has a strong grasp of technology. He is not afraid of trying out new things.

Ian is planning a holiday in Ireland, where he has never visited. He wishes to book a return-train journey from Dublin to Galway.

This site presented Ian with few challenges due to the error checking at individual key steps. It is easy to focus on the task at hand and the fact that the activities can be achieved rapidly.

Scenario: Researching and presenting a school project

"Anne" is a 13 year old school student who has been diagnosed with ADHD presenting as Combined. She needs to conduct an online research project on the extinction of the dinosaurs. She is expected to consult multiple sources, which need not be academic papers. They will enable her to prepare a 15-minute PowerPoint presentation to be delivered to her class. She has one month to prepare.

[Unlike the previous scenarios, this scenario does not concentrate on the individual-processing steps, but on the overall effect of the presentation of information.]

[As part of this scenario, 4 sites will be consulted. They will be assessed from Anne’s point of view as a person with ADHD.]

Causes of ADHD

The cause of the majority of ADHD cases is unclear. A number of factors may be involved in each case. Current research suggests that genetic factors are important in the development of ADHD [CDC-3]. ADHD appears to have a very-high heritability, independent of geographic location, associated with the Latrophilin 3 gene (LPHN3) (Arcos-Burgos, et. al., 2010). ADHD is commonly inherited from one or both parents. Children with siblings are 3 to four times more likely to develop ADHD than siblings of children without the disorder. Genetic factors are also thought to determine if the condition persists into adulthood (Franke, et al., 2012). Studies of the heritability of ADHD in adult populations are much-less common than studies in children.

In cases where heredity does not seem to be a factor, difficulties during pregnancy, prenatal exposure to alcohol and tobacco, premature delivery, significantly-low birth weight, excessively-high body-lead levels, and postnatal injury to the prefrontal regions of the brain, have all been found to contribute to the risk for ADHD to varying degrees [NRC-1]. In addition, exposure to organophosphates may result in symptoms similar to ADHD, but the results are unclear (de Cock, et. al., 2012).

Pathophysiology

It is widely recognized that ADHD is a neurodevelopmental disorder associated with functional impairments in some of the neurotransmitter systems of the brain, particularly those involved in the transmission of dopamine and norepinephrine [Wikipedia-1].

Children and adolescents with ADHD have brains that are 3-4% smaller than those of a control group. Basic neuroimaging research is being conducted to further delineate the pathophysiology of ADHD, determine diagnostic utility of neuroimaging, and elucidate the physiological effects of treatment. However, the research is currently not definitive enough for the practical application of neuroimaging [NRC-1].

Management

The management of ADHD typically involves counseling, medication, or a combination of both. Medication typically involves the use of psychostimulants, to boost and to balance levels of neurotransmitters present in the brain, and antidepressants [Mayo-1]. Significant and varied side effects may be associated with medication programs for ADHD. These side effects may vary as the patient ages [Mayo-1].

While treatment may reduce the effect of some of the symptoms associated with ADHD, it has not been shown to suppress all of the symptoms [Mayo-1].

Guidelines

Although there are no specific guidelines produced by a governing body, there are several non-medical ways to help an individual cope with effects of ADHD with respect to ICT. These are listed in the section: Specific technologies.

How Symptoms Result in Challenges for This Group

• may not pay attention to primary content because distracted by secondary content;
• may be confused by:
  • instructions that are not well-defined;
  • transitions among content-delivery types (e.g., text to video);
  • presentations of content using different formats or designs.

• may not participate in web-based interactions with other people;
• may not recall instructions when subsequently presented with an action to perform;
• may react negatively to auto-playing video or audio.

Observations from Interview with Anonymous User X

• Positive: web facilitates social communication between those who struggle with face to face communication.
• Negative: communication via the web allows people with ASD to become even more isolated.
• Often the web is avoided except for work or communication purposes as it is not very user friendly.
• Some websites specifically are avoided due to the predominant color (red is particularly bad).
• In many cases there are some very-useful accessibility features that users of websites and applications have the option to adjust. However, it is often difficult to find out how and where to do this. [Milliken-1]

Suggestions from Interview with Anonymous User X

• It is easier to view websites that are more visual and use only plain, simple language that doesn't contain any jargon.
• Numerous search results can be difficult to sort through to find the right link. Therefore, easy-to-access links are more helpful without many options.
• Font: very much a personal preference. However, in general:
  • big, plain fonts at least 12 point;
  • bold fonts not skinny;
  • sites that allow users to customize the font to their own preferences.

• color coordination for different parts of the site relating to each other;
• key for different colors for different sections;
• in some cases, poor concept of time means can be looking at one site/page/document for many hours without realizing - timer on screen to alert user to how long they have been on that page. [Milliken-1]

Scenario A: Use a Web Browser to Open a Web Page

"Trevor" is a bright 18-year-old who plays games and watches music videos on his laptop. He lives at home with his parents and younger sister. He attends a special school where the teachers and staff can help with his social and communication challenges from his Autism Spectrum Disorder, while he works to pass his high-school exams.

He has problems with visual information and recognizing things on the page. His reading skills are not helped by his trouble concentrating on the page or screen long enough to read. His teachers showed him how to make the text bigger on the page. They told him how to use a printable view to hide all the ads with moving images that distract him, because he reads every word on the page very carefully and literally. He can be easily confused by colloquialisms and metaphors. He can also be overwhelmed by sites that offer too many choices.

He likes using the school's forum to talk to his friends. It's easier to just read what they want to say than to listen and try to figure out their facial expressions.

He shares a laptop with the family, but has first dibs on it because his parents want him to get his schoolwork done. He uses it for homework, but he really likes games with repetitive actions. He doesn't like new sites much, in the same way that he doesn't like any changes in his routine: they are tolerated, but not encouraged." [Horton-1], [WebAIM-2]

Scenario B: Send an Email Message

Middle-aged female with PDD-NOS (Pervasive Development Disorder-Not Otherwise Specified). She experiences significant social deficits and meets all the diagnostic criteria for autistic disorder, but her stereotypical and repetitive behaviors are noticeably mild. She finds it easier to send an email message than communicate via speech with people as it eliminates any social anxiety she may experience when interacting with people in person.

Scenario C: Buy a Train Ticket Online

Older male with Asperger Syndrome who does not have any cognitive impairment. However, he exhibits repetitive behavior and has significant trouble with social situations, specifically communicating with others. He prefers to buy his train tickets online as it eliminates any social interaction which he is not keen on. He struggles to communicate with others successfully. He has extreme anxiety. He has been either unable to purchase a ticket in person, or ended up with the wrong ticket through his lack of ability to express what he needs specifically to the ticket-office attendant. When buying train tickets, there is noticeable task avoidance amongst many people on the spectrum.

Scenario D: Shop an Online Supermarket

Young adult male with 'classic' Autism. He has a severe cognitive delay and is non-verbal, a side effect of which is extreme social inhibition. He is able to communicate via pictures when necessary with his family and carers. A local supermarket is a good example of a place where he can easily become overwhelmed, which severely affects his ability to communicate effectively. However, in the comfort of his own home he is much better able to function, and therefore is less dependent upon others for help. The task of online shopping is made much easier if a very- specific item is required and there is little choice.

Consistency

• "Ensure that navigation is consistent throughout a site.
• Similar interface elements and similar interactions should produce predictably similar results."[WebAIM-2]

Transformability

• "Support increased text sizes.
• Ensure images are readable and comprehensible when enlarged.
• Ensure color alone is not used to convey content.
• Support the disabling of images and/or styles." [WebAIM-2]

Multi-modality

• "Provide content in multiple mediums.
• Use contextually-relevant images to enhance content.
• Pair icons or graphics with text to provide contextual cues and help with content comprehension." [WebAIM-2]

Focus and Structure

• "Use white space and visual design elements to focus user attention.
• Avoid distractions.
• Use stylistic differences to highlight important content, but do so conservatively.
• Organize content into well-defined groups or chunks, using headings, lists, and other visual mechanisms.
• Use white space for separation.
• Avoid background sounds." [WebAIM-2]

Readability and Language

• "Use language that is as simple as is appropriate for the content.
• Avoid tangential, extraneous, or non-relevant information.
• Use correct grammar and spelling.
• Use a spell-checker. Write clearly and simply.
• Maintain a reading level that is adequate for the audience.
• Be careful with colloquialisms, non-literal text, and jargon.
• Expand abbreviations and acronyms.
• Provide summaries, introductions, or a table of contents for complex or lengthy content.
• Be succinct.
• Ensure text readability.
  • Line height: The amount of space between lines should generally be no less than half the character height.
  • Line length: Very long lines of text (more than around 80 characters per line) are more difficult to read.
  • Letter spacing, word spacing, and justification: Provide appropriate (but not too much) letter and word spacing. Avoid full justified text as it results in variable spacing between words and can result in distracting "rivers of white" - patterns of white spaces that flow downward through body text.
  • Sans-serif fonts: These fonts are generally regarded to be more appealing for body text.
  • Adequate text size (Very small text): Text should generally be at least 10 pixels in size.
  • Content appropriate fonts: Visually appealing and content-appropriate fonts affect satisfaction, readability, and comprehension.
  • Paragraph length: Keep paragraph length short.
  • Adequate color contrast: Ensure text is easily discerned against the background and that links can be easily differentiated from surrounding text.
  • No horizontal scrolling: Avoid horizontal scrolling when the text size is increased 200-300%." [WebAIM-2]

Orientation and Error Prevention/Recovery

• Give users control over time sensitive content changes: Avoid automatic refreshes or redirects. Allow users to control content updates or changes. Avoid unnecessary time-outs or expirations. Allow users to request more time.
• Provide adequate instructions and cues for forms: Ensure required elements and formatting requirements are identified. Provide associated and descriptive form labels and fieldsets/legends.
• Give users clear and accessible form error messages and provide mechanisms for resolving form errors and resubmitting the form.
• Give feedback on a user's actions: Confirm correct choices and alert users to errors or possible errors.
• Provide instructions for unfamiliar or complex interfaces.
• Use breadcrumbs, indicators, or cues to indicate location or progress: Allow users to quickly determine where they are at in the structure of a web site (e.g., a currently active "tab" or Home > Products > Widget, for example) or within a sequence (Step 2 of 4). Next/Previous options should be provided for sequential tasks.
• Allow critical functions to be confirmed and/or canceled/reversed.
• Provide adequately-sized clickable targets and ensure functional elements appear clickable: Use labels for form elements, particularly small checkboxes and radio buttons, and ensure all clickable elements appear clickable and do not require exactness.
• Use underline for links only.
• Provide multiple methods for finding content: A logical navigation, search functionality, index, site map, table of contents, links within body text, supplementary or related links section, etc. all provide multiple ways for users to find content." [WebAIM-2]

Guidelines

• Cognitive Web Accessibility Checklist (Last Updated September 2, 2009). WebAIM, Center for Persons with Disabilities, Utah State University.
• Friedman M, Bryen D (2007). Web accessibility design recommendations for people with cognitive disabilities. Technology and Disability; 19(4): 205-212.
• Designing websites suitable for people with autism spectrum disorders (Last Updated March 16, 2008). The National Autistic Society.
• Poulson D, Nicolle C (2004). Making the Internet accessible for people with cognitive and communication Impairments. Universal Access in the Information Society; 3(1): 48-56.
• Telecommunications Problems and Design Strategies for People with Cognitive Disabilities (Last Updated August 16, 1999). World Institute on Disability.

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.

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.

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.

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.

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.