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Successful Assistive Technology Service Delivery Outcomes from Applying a Person-Centered Systematic Assessment Process: A Case Study

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Background. The assistive technology assessment (ATA) process developed by Federici and Scherer [1] provides professionals with guidelines for an effective outcome in the AT selection and assignment process with the aim to match person and assistive technology (AT). Purpose. A case study open out as the ATA process is put into practice, leading the user and the multidisciplinary team of the service delivery to an assistive solution. Method. Case study on a 6.5-year-old female child with a dystonic component as an outcome of cerebral palsy from birth, attending a three-year-AT-assessment-process. Conclusion. The case report highlights well the roles of the psychotechnologist and the psychologist throughout the phases of the ATA process. The environmental assessment procedure brings clarity to measures of accessibility, universal design, and sustainability, and captures well the three perspectives on the interaction between person and AT in the user’s environments.
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Life Span and Disability XVIII, 1 (2015), 41-74
41
Successful assistive technology service delivery
outcomes from applying a person-centered systematic
assessment process: a case study
Stefano Federici1, Fabrizio Corradi2, Fabio Meloni3, Simone Borsci4,
Maria Laura Mele5, Saveria Dandini de Sylva6 & Marcia J. Scherer7
Abstract
Background: The assistive technology assessment (ATA) process
developed by Federici and Scherer in 2012 provides professionals with
guidelines for effective outcomes in assistive technology (AT) selection
and assignment process with the aim to match a person with AT.
Purpose: This paper has sought to verify the effectiveness of the ATA
process model through its application in a centre for technical aids in
severe motor disability cases. Method: The ATA process was applied to a
case study of a 6.5-year-old female child with cerebral palsy during a
1Department of Philosophy, Social & Human Sciences and Education, University of Perugia, Perugia, IT.
E-mail: stefano.federici@unipg.it;
2Leonarda Vaccari Institute for Rehabilitation Integration and Inclusion of Persons with Disabilities,
Rome, IT. E-mail: fabrizio.corradi@gmail.com;
3Department of Philosophy, Social & Human Sciences and Education, University of Perugia, Perugia, IT.
E-mail: fa.meloni@gmail.com;
4Imperial College of London, National Institute for Health Research, Diagnostic Evidence Cooperative
group of London, UK. E-mail: simone.borsci@gmail.com;
5Department of Philosophy, Social & Human Sciences and Education, University of Perugia, Perugia, IT.
E-mail: marialaura.mele@gmail.com;
6Leonarda Vaccari Institute for Rehabilitation Integration and Inclusion of Persons with Disabilities,
Rome, IT. E-mail: presidenza@leonardavaccari.it;
7The Institute for Matching Person and Technology, Webster, NY, USA. E-mail: IMPT97@aol.com;
Correspondence to: Prof. Stefano Federici, Department of Philosophy, Social & Human Sciences and
Education, University of Perugia, Piazza G. Ermini 1, 06123 Perugia, IT; e-mail:
stefano.federici@unipg.it; Tel.: +39 347 3769497.
The authors declare they have no conflicts of interests to be disclosed.
Received: April 22, 2014; Revised: February 28, 2015; Accepted: March 7, 2015
© 2015 Associazione Oasi Maria SS. - IRCCS
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period of three years. The process consisted of three 12-monthcycles of
AT assessment, matching, and assignment. The first cycle focused on the
evaluation of the user’s requests and the assistive solution assessments,
while the last two cycles focused on the post-assignation follow-up, and
re-evaluation of the previous solutions by fine-tuning AT assignations.
Results: After several multidisciplinary team meetings and an
environmental evaluation, the child was provided with an E-Tran, a
scanning system utilizing Clicker software, a new postural system, and
eye-tracking system solution. The ATA process model guided the centre’s
professionals and the user’s milieu to better analysis and comprehension
of the user’s needs. The effectiveness of the ATA process was highlighted
by the user’s improvement in autonomy, social integration and
communication, and in oculi-motor and postural control. Conclusions:
This case study highlights how a multidisciplinary and user-focused
assessment process is effective over time. The roles of the
psycho-technologist and the psychologist throughout the phases of the
ATA process emerged as fundamentally important to reach an effective
outcome in an ATA process.
Keywords: Assistive technology; Service delivery; Psycho-technologist;
Psychologist; Matching person and technology; ICF-CY;
Case study.
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1. Introduction
As pointed out by Lancioni and colleagues, there are two large groups of
people with disability who may particularly benefit from assistive
technology (AT):
“(a) students with combinations of motor or sensory-motor and
communication disabilities and typical or nearly typical level of
intellectual functioning, and (b) persons with severe/profound
intellectual disabilities or combinations of motor or sensory-motor
impairment and intellectual disabilities or consciousness disorders”
(Lancioni, Sigafoos, O‟Reilly, & Singh, 2013, p. 2).
Currently, many assistive solutions have been proposed to improve the
quality of life of people with disability. Current assistive solutions are based
on low-tech devices, such as non-electronic tablets and boards, see for
example the E-Tran (eye transfer) communication board, or high-tech
electronic/electric devices which can be used, for instance with only a single
body gesture as an input controller, e.g., a microswitches or gaze-based
interfaces (Lancioni & Singh, 2014).
The state of the art literature on intellectual and developmental
disabilities shows growing attention to the evolution of ATs for fostering
autonomy, participation, and rehabilitation for persons with special
education and communication needs. An example of an assistive solution
designed to meet the special need of persons in developmental age with a
combination of motor or sensory-motor and communication disabilities was
recently proposed by Stasolla and colleagues (Stasolla, Caffo, Picucci, &
Bosco, 2013). Specifically, the authors developed an assistive solution that
combines microswitches with a computer-aided set-up for helping
individuals in developmental age to communicate their needs by choosing
items along a series of subsequent steps that are hierarchically structured.
The Assistive Technology Assessment (ATA) process is a model
developed by Federici and Scherer (2012b) with the contribution of 55
scholars from five continents, offering a sequential set of assessments for
matching a person with assistive technology (AT) to professionals with
different areas of expertise in specialized service delivery in rehabilitation
technology (Scherer, 2002, 2005; Corradi, Scherer, & Lo Presti, 2012;
Federici & Scherer, 2012a) .
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The ATA process models the functioning process of centers for AT
evaluation and provision independently of the model for local or national
service delivery systems. The ATA process borrows a user-driven working
methodology from the Matching Person and Technology (MPT) model of
Scherer (Scherer, 1998; Corradi et al., 2012, p. 52). Furthermore, the ATA
ideal model embraces the ICF bio-psycho-social model promoted by the
International Classification of Functioning, Disability and Health (ICF;
WHO, 2001), aiming at the best combination of ATs to promote the
customer‟s personal well-being (for an extensive explanation of the ATA
process model, see: Federici & Scherer, 2012b; Federici, Scherer, & Borsci,
2014).
One of the main features of the ATA process is the twofold perspective
of its flow. In fact, it can be read both from the user or from the perspective
of AT service delivery (Federici, Scherer, et al., 2014). Since the ATA
process is a user-driven process, any activity of AT service delivery must
find correspondence with a user action and vice-versa. The ATA process
model is built on five pillars from disability studies and rehabilitation
research:
1. The bio-psycho-social model proposed by the ICF. All the
dimensions affecting the user‟s functioning (health condition and
contextual factors) must be evaluated when analyzing the user‟s
request and choosing the appropriate assistive solution.
2. The MPT model. This model overcame the traditional dyadic and
one-way assessment process which involves the user in the AT
selection only after the assignation. Following this more advanced
model, three factors (i.e., the person, the milieu/environment, and
the technology) must be considered as a part of the whole process
when selecting the most appropriate AT solution.
3. The definition of an assistive solution. This was proposed by the
Association for the Advancement of Assistive Technology in
Europe (AAATE) in 2003 as follows: Overcoming a disablement
may involve something more than just a device, it often requires a
mix of mainstream and assistive technologies whose assembly is
different from one individual and another, and from one context to
another. We may label it assistive solution (AAATE, 2003, p. 2).
4. The definition of psycho-technologist: the psycho-technologist is an
expert in psychology, AT, and human factors. The role of
psycho-technologists includes analyzing and evaluating the
interaction between users and technology by taking into account
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the psychological and cognitive components of the interaction. In
contrast with the psychologist, the psycho-technologist primarily
focuses on the technological side of matching the person with
technology and is less oriented to the clinical and psychological
dimensions of the user‟s interactions.
5. The role of the psychologist. The psychologist in an AT service
delivery process, as an expert in human factors, provides
appropriate psychological evaluation or precise clinical
intervention with the users and/or their significant human context
over the course of the whole AT assignment process. Investing in
personal factors represents an important turning point for a
successful match between person and technology (Meloni,
Federici, & Stella, 2011; Meloni, Federici, Stella, Mazzeschi,
Cordella, Greco et al., 2012).
The present article is a continuation of two previous ones (Federici,
Corradi, Meloni, Borsci, Mele, Dandini de Sylva et al., 2014; Federici,
Scherer, et al., 2014) where a cross-cultural comparison of AT service
delivery systems and the application of the ATA process model adopted by
the Leonarda Vaccari Institute of Rome was discussed. The purpose of this
study was to verify the effectiveness of the ATA process model through its
application in an AT Service Delivery centre to Arianna, a 6.5 year-old
female child, with a dystonic component as an outcome of cerebral palsy
from birth, attending a three-year AT assessment process.
2. Method: A Rehabilitation Technology Case Study
In the present work, a case study will illustrate the ATA process in
practice, leading the user and the multidisciplinary team of the service
deliverer to an assistive solution. The case report will be mainly focused on
the roles of the psycho-technologist (Federici, Corradi, Mele, &
Miesenberger, 2011; Miesenberger, Corradi, & Mele, 2012) and of the
psychologist (Meloni et al., 2011; Meloni et al., 2012) within the phases of
the AT Service Delivery process (Federici & Scherer, 2012b). The following
case study describes a three-year AT assessment process carried out at the
Leonarda Vaccari Institute (Federici, Corradi, et al., 2014). During this
period, three cycles of the ATA process were performed as shown in Figure
1. Six steps (from A to F) are temporally sorted around the flow chart of the
AT Service Delivery process (Federici, Corradi, et al., 2014), synthesizing
the main issues related to the assessment‟s steps: the two user requests in
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step A of the first cycle; the assistive solutions proposed by the
multidisciplinary team in each cycle at steps B, D, and F; and the follow-up
regarding the first and second cycle in steps C and E. In Table 1, for each
cycle the sequence of events is listed regarding the ATA process applied to
Arianna pointing out the professionals‟ interventions, the user‟s features and
achievement, and the AT assigned. The period of time is specified for each
cycle.
Before starting the AT assessment, during phase A (Fig. 1), the parents
were required to provide to the Institute Arianna‟s clinical and observational
data and medical history. As observational data the parents were suggested
to video-record (about 10 minutes) Arianna‟s behavior in family and school
contexts.
Figure 1 - ATA process cycles
The flow chart depicts the three cycles of the ATA process for Arianna‟s case. In the middle of
the figure the AT Service Delivery process (Federici, Corradi, et al., 2014) for each cycle is
drawn. Each cycle has a duration of about 12 months. In step A of the first cycle, the two user‟s
requests are reported. In steps B, D, and F the assistive solutions proposed by the
multidisciplinary team in each cycle are summarized. Finally, in steps C and E the outcome of the
follow-up regarding the first and second cycles are displayed.
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2.1. Case description from clinical data and medical history
Arianna was 6.5 years old when she was brought by her parents in 2008
to the Institute Leonarda Vaccari, with a diagnosis of severe spastic
quadriplegia with a dystonic component as outcomes of cerebral palsy from
birth (Table 1). Arianna was very interested in objects that were presented to
her and she attempted in all ways to reach and grasp them, but was unable to
implement the action due to the presence of significant dystonia. With
regard to visual and perceptual functions, specific strategies and a specific
interaction with her were used in order to evaluate her abilities. In particular,
the symbols of Hyvärinen (circle, square, sweetheart, and cottage) were used
(Hyvärinen & Jacob, 2011). The child had good visual acuity
(OD = 9 10/10 Dpt; OS = 10/10 D.; OU = 11/10 Dpt)8 and a normal color
sense, sensitivity to contrast and field of vision. Moreover, the child
managed to perceive and locate objects in both the proximal and distal
distance, with good ability to fix and track. She moved voluntarily within
the room using a motorized wheelchair.
At the time of the observations, Arianna had difficulty in separating
herself from her mother, crying and calling for her repeatedly when her
mother left. Arianna had excellent cognitive resources, appearing to be very
communicative and participatory in the environment. She used adequate and
appropriate augmentative and alternative communications, both by request
and declaratively, being able to communicate complex moods and affection
with a motivated and contextual smile, responding to closed questions yes
with anti-flexion of the head, and no with slight lateral movements of the
head side to side. She demonstrated understanding of requests, thus the
operator could always explain what he or she was about to do and ask her
what she preferred.
The mother contacted the Institute inquiring about an evaluation to
determine technological strategies and assistance to enhance Arianna‟s
communication. Both parents signed an informed written consent, before
starting the assessment process at the Leonarda Vaccari Institute, also
explicitly accepting to participate in the present study with the participation
of the University of Perugia.
8 OD = Oculus Dexter (right eye); OS = Oculus Sinister (left eye); OU = Oculus Uterque (both eyes); Dpt =
diopter.
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Table 1 - Case description according to the WHO’s international
classification of diseases (ICD-9 and ICD-10), individual
functioning (ICF-CY), and Vineland’s measures of adaptive
behavior
ICD-9: International Statistical Classification of Diseases and Related Health Problems,
9th Revision (WHO, 1977)
&
ICD-10: International Statistical Classification of Diseases and Related Health Problems,
10th Revision (WHO, 1992)
ICD-9
ICD-10
Congenital
quadriplegia
Congenital
quadriplegia
G80.0
ICF-CY: International Classification of Functioning, Disability and Health
Children and Youth Version (WHO, 2007)
Body functions
Body structures
Activities and
participation
Environmental factors
b114.1
Orientation
functions
s110.8
Structure
of brain
d140.30
Learning
to read
e310+4
Immediate
family
b140.0
Attention
functions
s730.4
Structure
of upper
extremity
d145.30
Learning
to write
e320+4
Friends
b144.0
Memory
functions
s750.4
Structure
of lower
extremity
d310.30
Communicating
with
receiving-spoken
messages
e325+4
Acquaintances,
peers,
colleagues,
neighbors
and community
members
b167.1
Mental
functions of
language
d330.44
Speaking
e330+4
People in
positions
of authority
Vineland Adaptive Behaviour Scales (Sparrow, Balla, & Cicchetti, 1984)
Domain
Raw
Score
Equivalent
Age
Subdomain
Raw
Score
Equivalent
Age
Communication
70
1-9
Receptive
46
2-9
Expressive
15
< 1-6
Written
9
3-10
Daily Living
Skills
40
1-8
Personal
28
< 1-6
Domestic
0
< 2-2
Community
12
2-9
Socialization
65
1-11
Interpersonal
relationships
34
< 1-6
Play and leisure time
25
1-6
Coping skills
6
1-3
Motor Skills
8
< 1-6
Gross
6
< 1-6
Fine
2
< 1-6
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2.2. ATA Process First Cycle
2.2.1. First Multidisciplinary Team Meeting for Data Evaluation and
Setting Design
At the first multidisciplinary team meeting (Fig. 1 and Tab. 2), the
psycho-technologist chaired the team, coordinated the professionals‟
interventions and wrote the meeting‟s report. The other participants included
the psychologist, the pediatric specialist in AT, the developmental
neuro-psychometrician, the occupational therapist, the orthopedic
technician, the physiatrist, the architect, and the engineer.
According to the psychologist‟s report, two requests were made to solve
activity limitations and participation restrictions in two specific milieus:
home with family and school. The psychologist summarized the two
requests as follows (Figure 1 and Table 2, step A):
Identification of ATs that allow Arianna to keep up with the school‟s
curriculum.
Checking the use of Augmentative and Alternative Communication
(AAC) strategies adopted by the family without an expert consult and,
eventually, including a new AT for communication to facilitate daily
communication with a variety of children and adults.
The psychologist showed Arianna‟s functional profile and diagnosis to
the team, restructured according to the ATA process matching model, and
summarized her individual functioning under the lens of the
bio-psycho-social model.
Arianna’s functioning regarding health and personal factors. Arianna,
6.5 years old, was attending the first grade in primary school, following a
curriculum for students with special needs. Her prognosis was favorable
regarding reading and writing. She used, when requested, a book with
pictures to tell about her experiences and a binder with figures, pictures, and
icons for communicating. She adequately and clearly expressed “yes” and
“no” with head and eye movements. She pointed grossly with her right fist,
because of her low muscle and gaze control. For communicating, Arianna
used a code of facial mimicry and gaze shared by the caregivers but not
understandable to unfamiliar people. From the documentation gathered, she
was described as intelligent, motivated, lively, cheerful, attentive, and very
communicative.
Arianna’s functioning regarding environmental factors. There was an
absence of a rehabilitation team of reference. The parents, networked with
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the school, were the developers of the AAC intervention. The milieu was
careful in respecting Arianna‟s time and manners, facilitating activities
appropriate in content and form, and was available to work for the inclusion
of alternative strategies for communication and education. The mother
played the role of “interpreter” of the code of communication (gaze and
facial mimicry) used by Arianna. The milieu showed high expectations with
respect to the insertion and use of ATs by Arianna.
Arianna’s predisposition to technology use. The Survey of Technology
Use (Federici, Corradi, Lo Presti, & Scherer, 2009) tool provided evidence
that Arianna generally seemed happy at home and school; easy-going;
expressive/outgoing; impatient; motivated; sticks to a task; flexible; curious;
and cooperative.
Arianna’s functioning regarding technological factors. She used the
following AACs: notebook with her experiences, binder with figures,
pictures, and icons created by the family via Boardmaker® (by Mayer-
Johnson). To move around, Arianna used an electric wheelchair, with
joystick control and adapted yoke, walking stroller, and a pediatric postural
mobility stroller. The Matching Assistive Technology and Child: MATCH
(Federici et al., 2009) assessment tools provided evidence of Arianna‟s good
predisposition to the use of ATs.
The multidisciplinary team entrusted the psycho-technologist to check
which ATs and/or alternative strategies to adopt to facilitate autonomous
communication by Arianna (i.e., without the necessary interpretation of her
mother), and for supporting scholastic learning in relation to the current
situation of the child and her environment. With regard to ATs, the
psycho-technologist proposed the following possible solutions to the
multidisciplinary team (Fig. 1 and Tab. 2, step B):
ATs for communication:
E-Tran (eye transfer). The eye gaze communication board, E-Tran,
allows for rapid communication with a facilitator. The E-Tran, a
transparent Plexiglas board with alphanumeric and icon labels applied,
would initially be arranged with the same images as Arianna‟s binder,
with figures, pictures, and icons. Such a solution was proposed
because of her very marked involuntary movements, which prevented
the use of the upper limbs in a functional way, but showed the
presence of sufficient head control and preserved visual functionality.
Communication boards reorganized. Arianna‟s current binder would
be reorganized by easily searchable topics and be integrated by
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printing new necessary images through the use of the Boardmaker®
Software already in her use.
AT for learning and independent living:
Automatic scanning system. The system consists of a Jelly Bean
switch (2.5 inches by AbleNet), a MultiKey (by Auxilia) adapter to
connect the switch to the computer, and the Clicker software (by Crick
Software), adaptable according to needs by Arianna‟s schoolteachers,
set to automatically scan. Through automatic scanning, Arianna can
experience the computer for simple tasks that require control of time,
in turn getting practice in seeing herself as a subject “that can make it
alone (independence). This would be a temporary solution to bridge
the gap between the current use of the fist with the communication
board and the novelty of the computer. It minimizes the cognitive
workload through simple activities and games, giving her the
possibility of her first autonomous management of the tools provided.
AT for improving posture and mobility:
After watching the video produced by Arianna‟s mother on the main
activities of her daily life (see above), the physiatrist found an
inadequate posture system was in use. Therefore, the
psycho-technologist provided suggestions to the multidisciplinary
team in order to individualize a modular and customized postural
system that could improve her posture, integrating and supporting the
AT for learning and communication. The physiatrist and the
orthopedic technician, on the basis of the user‟s needs and indications
provided by the psycho-technologist, proposed the Junior postural
system by Jenx as the best postural solution. The system allows for
active postures to perform all operations necessary to use the ATs
assigned with minimal effort and maximum performance.
Therefore, with respect to the user‟s requests, the psycho-technologist
submitted to the multidisciplinary team AT solutions of a high-tech type for
learning as well as low-tech type for communication. The assistive solution
process initially started by maintaining the user‟s current system and then,
gradually continuing to modify the overall system because it supports and
integrates the new AT for learning and communication.
At the end of the meeting, the multidisciplinary team assigned to the
psycho-technologist suggested the set-up of the assessment setting for the
matching evaluation. At the same time, given that the new postural system
integrated with AT for learning and communication foresaw an
environmental impact, the engineer and the architect were charged with
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providing a more accurate evaluation of Arianna‟s context of use. This
environmental assessment process (Federici, Corradi, et al., 2014) would be
activated if the user accepted the proposals during the matching process.
Matching Process: Proposal, User-Trial, and Outcome of the Assistive
Solution. At the matching process, Arianna, her mother, her school teachers,
and the multidisciplinary team were in attendance. During the user-trials, the
physiatrist and the orthopedic technician tested the postural system, and the
psycho-technologist and the occupational therapist tested the ATs. The
engineer and the architect checked the need for environmental modification
and adaptation with the mother and the teachers. The psycho-technologist
coordinated the trials and wrote the meeting report about the outcome of the
matching process. The psychologist observed interactions between Arianna
and her mother, and between Arianna and her school teachers, both in the
test phase of the postural system and the AT matching tests. He also checked
directly with the child, through simple gestural communication and
observation of postural, gestural, and paralinguistic elements, regarding the
level of satisfaction with each AT match.
The physiatrist and the orthopedic technician tested the Junior postural
system by Jenx. It was fitted and customized by the orthopedic technician
under the supervision of the physiatrist. The matching test for the AT
postural system was evaluated very positively, because the system allows for
active postures to perform all operations necessary with minimal effort and
maximum performance.
Then the psycho-technologist and the occupational therapist tested the
ATs for communication, learning, and independent living. The
psycho-technologist reported the following outcomes and judgments on the
matching process for each AT tested:
About the E-Tran, Arianna immediately understood the E-Tran mode
of use, controlling eye movements in a precise and fast way, although
an excessive speed of shifting between different targets was
detrimental to message clarity. She showed the ability to lengthen the
time of eye fixation upon request; sometimes she put into action
several attempts to accompany the eye fixation with her fist (the
method adopted to indicate the icons on her communication boards).
The matching test was evaluated very positively.
About the reorganized communication boards, Arianna showed an
adequate understanding of the symbols and their functions,
highlighting difficulties in browsing the boards and in identifying the
location of the target symbol/image. She had dysmetria with her right
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fist in the indication gesture. The matching test was evaluated
positively.
About the scanning system Clicker software, Arianna understood well
the mode of use, although she was not able to independently manage it
with reference to time and presented difficulties maintaining pressure
on the sensor in a consistent manner. She had dysmetria in reaching
for the sensor. The matching test was evaluated positively.
The psychologist noted that:
Arianna seemed excited mainly by the E-Tran and quickly
demonstrated the ability to assume good mastery of it. The child
seemed to be aware of the potential of E-Tran, which can probably
satisfy both her need for greater autonomous communication and her
desire to interact with a greater number of people. Both her mother
and her schoolteachers seemed to positively consider the appreciation
and ease of use of the tool by Arianna. The psychological evaluation
of this matching test was highly positive. Arianna was deeply engaged
and enthusiastic with the technology, because she saw in the use of the
E-Tran a chance to facilitate communication with others.
As far as the other two tools were concerned - the reorganized
communication board and the scanning system Clicker software -
Arianna encountered several difficulties (in browsing the board and
identifying the location of target symbols/images for the
communication board, being dependent on others for use of her AT,
and difficulties in maintaining pressure on the sensor for the scanning
system) as reported by the psycho-technologist. Those limitations
indicated a requirement for a longer period of mutual adaptation.
Nevertheless, her mother and schoolteachers appreciated the
educational potential of both technologies. The potential of this AT
match was strongly positive in spite of the critical issues regarding a
greater commitment by the family and the schoolteachers. Finally,
some customized refinements of the tools are likely to be made later to
better facilitate their use.
The engineer and the architect analyzed Arianna‟s house and classroom
based on all three environmental dimensions: accessibility, usability, and
sustainability (Mirza, Gossett Zakrajsek, & Borsci, 2012). The analysis was
carried out using maps of the environments, by looking at a video of
Arianna‟s daily activities, and by inviting her schoolteachers to describe the
position of Arianna‟s desk in the classroom. This qualitative analysis
suggested that the two environments (house and classroom) had no
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accessibility problems, whereas two warnings about the classroom
environment were reported by professionals: the first one concerned the fact
that Arianna could use the Clicker software only in a safe and well
illuminated space (usability), and the second concerned proximity to an
electrical outlet to provide energy to Arianna‟s systems (sustainability). At
the end of this analysis, the professionals suggested an onsite analysis of the
relationship between Arianna and the ATs in the classroom environment.
2.2.2. Second Multidisciplinary Team Meeting for the Assistive Solution
Proposal
At the second multidisciplinary team meeting, the psycho-technologist
chaired the meeting, coordinated the professionals‟ interventions and wrote
the meeting report. The other participants included the psychologist, the
pediatric specialist in AT, the developmental neuro-psychometrician, the
occupational therapist, the orthopedic technician, the physiatrist, the
architect, and the engineer. Based on the psycho-technologist‟s report on the
matching process outcomes, the multidisciplinary team believed they had
identified the best assistive solution to propose to the user among the ATs
tested. They issued the following recommendations.
About the E-Tran, Arianna should make constant use of it, even
though it was a novelty for her, learning how to use it and discovering
its communicative potential, with the aim of facilitating faster
communication than the current system allowed.
About the reorganized communication boards, they should be used in
a more familiar and quiet communicative setting (rather than in the
school) after reorganizing the actual boards and inserting a content
index board. Moreover, inserting the symbol “there isn‟t a symbol”
using the Boardmaker® Software was suggested. The team did not
consider the communication boards as an optimal solution, but given
that at the moment, it was the most rewarding communicator for the
user and was already known from the milieu, supporting and allowing
Arianna‟s participation and initiative communicative, it should be
maintained.
About the scanning system Clicker software, it should be uploaded in
the school with teaching units identical to class content. Arianna
should initially be supported using the automatic scanning system and
then, gradually, reduce the need for support with the aim of
autonomous management.
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About the Junior postural system by Jenx, it should be adapted by
placing a sensor for automatic scanning on the outside right of the
system. Initially, during computer activities, Arianna‟s left arm should
be anchored, with the aim of creating a point of stability and limiting
the dystonic component. Subsequently, the child should be supported
in looking for her own strategy in order to exclude external constraints
to the left arm.
The psychologist invited the multidisciplinary team not to overlook some
points of weakness that emerged during the matching test: the objective
difficulties of the child in relation to the most technologically advanced
tools; and Arianna‟s difficulties with the technological tools, coupled with
the enthusiasm from the mother, could contribute to maintaining a strong
relational dependence of the child on the mediation of the mother. The
markedly technological component of the communication board and the
scanning system could be a main factor for the integration of Arianna within
the class. Moreover, these signs reassured schoolteachers about the difficulty
of holding together the class group as learning advances. At the same time,
the team should actively promote the use of the E-Tran at this stage that is
less technological but of greater help for Arianna to achieve greater
communicative autonomy. In this particular case, a change too quickly to the
most advanced technological tools could be a “double-edged sword”: the
price of greater integration, for example at school, may be the maintenance
of prolonging dependence on the mother or adults in general.
The environmental evaluation, starting from the warning of the
qualitative analysis, was carried out by professionals as a performance
analysis of Arianna in interaction with (i) the scanning system Clicker
software (ICF-CY code = e1251) by using the postural system in the
classroom, (ii) the electrical wheelchair adapted with an joystick and cloche
(ICF-CY code = e1201). This test was performed with Arianna sitting (i) at
her usual desk, in a central position, and (ii) in a new desk position. The new
position of the desk was selected by professionals for the following reasons:
(1) it was more peripheral from the centre of the classroom and closer to the
wall (but still not isolated) than the usual desk of Arianna, reducing the
possibilities that her schoolmates could accidentally damage the system; (2)
it had a higher level of illumination than the central position
(ICF-CY code = e2400); and (3) it was close to an electrical outlet
(ICF-CY code = e1501). Arianna‟s time of performance was assessed by
using 5 different tasks for each trial; the time performance measured at the
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centre (M = 14.46 s; DS = 5.55 s) was used by professionals as a
comparative index of performances. The findings obtained were as follows:
When the scanning system Clicker software was tested in a central
position, Arianna‟s interaction was very slow (M = 23.53 s,
DS = 4.68 s). The scanning system in this position was not considered
by professionals as a facilitator (ICF-CY code = e1251+0) as well as
the electrical wheelchair (ICF-CY code = e1201+0); the low
illumination and the distance from the socket unit acted as severe
environmental barriers (ICF-CY codes = e2400.3 and e1501.3).
When the scanning system Clicker software was tested in a peripheral
position, Arianna seemed more comfortable, due to the optimal level
of illumination. Nevertheless, she was not driven to control her hand
movements by the electrical wheelchair (M = 21.49 s; DS = 2.09 s). In
that case, the illumination and the access to the sockets acted as
facilitators (ICF-CY codes = e2400+4 and e1501+4) whereas the
electrical wheelchair and the scanning system Clicker software still
had not properly supported Arianna (ICF-CY codes = e1251+0 and
e1201+0).
Finally, Arianna was invited to test the scanning system Clicker software,
sitting in the Junior postural system previously tested in the centre. This test
was only run with the desk in the new peripheral position. With the use of
this kind of postural system, the time of Arianna's performances were very
close to her performances at the centre (M = 15.11 s; DS = 2.07 s). At the
end of this test, Arianna was administered via E-Tran the device scale of the
QUEST 2.0 (Device = 28; Services = 16; Average Satisfaction = 3.17). The
interaction with the scanning system Clicker software was self-evaluated as
satisfactory (M = 3.11; DS = 0.44). At the end of their report, the engineer
and the architect proposed that the scanning system Clicker software could
be used as a complete facilitator (ICF-CY code = e1251+4) only when
associated with the Junior postural system tested at the centre (ICF-CY code
= e1151+3). They also recommended the use of the postural system in the
house in order to optimize Arianna‟s skills in the use of the complex systems
of interaction and to reduce the effort of her interactions in the home
environment.
User agreement. The user, together with her parents and schoolteachers,
were convened (Figure 2, phase 4, step [h]) by the psychologist. At the
meeting, the psycho-technologist was present too. First of all, the
psychologist invited the user and her caregivers to express their opinions on
the ATs tested in the matching process. Arianna showed curiosity and
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enthusiasm about the solution proposed whereas the mother and the
schoolteachers expressed positive evaluations about the ATs proposed and
seemed to have higher expectations, particularly for the scanning system
Clicker software. Then, the psychologist warned the mother and the
schoolteachers that given that to date Arianna had never been exposed to
any assistive information technology, this poor user experience could affect
the use of the AT assigned (scanning system). Therefore, the path to
independence in communication and learning would involve a progressive
acquisition of new skills such as „waiting-for-your-turn‟ during a
conversation, a greater ability to „do by herself‟, in an average time that
would be evaluated in the following meetings and in the follow-up support.
Then, the psycho-technologist explained each AT suggested by the
multidisciplinary team and the recommendations for use. Finally, the
psychologist and the psycho-technologist scheduled a meeting for training
and support in the use of the assistive solution.
Figure 1 - The psycho-technologist’s actions in the AT Service Delivery flow
chart according to the ATA process model (Federici, Corradi, et
al., 2014). Button numbered signs show the steps of participation
for the psycho-technologist’s intervention
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User Support and Follow-up. For twelve months, the user support
(Figure 2, phase 4, step [j]) for AT training and the E-Tran customization
was activated immediately after Arianna was provided with the ATs and
postural system (Figure 2, phase 4, step [i]). At the end of the twelve
months, a follow-up meeting was scheduled in which Arianna, her mother,
and the schoolteachers took part along with the psychologist and the
psycho-technologist. The psycho-technologist chaired the meeting and wrote
the meeting report. With regard to each AT assigned it emerged that (Figure
1, step C):
The E-Tran was not used at home and scarcely at school because it
was viewed as low-tech.
The Communication boards were used spontaneously by the user in
all environments. Arianna‟s classmates played the role of facilitators.
It was reorganized according to the recommendations received,
including many new symbols and figures with considerable increase
in volume. Issues remained regarding Arianna‟s independent
management of the tool.
The scanning system Clicker software was fully managed
independently. It was used at home for adapting Arianna‟s preferred
books and at school for creating personalized learning units.
The postural system addressed the issues posed by the environment
and the needs of the user in relation to the use of technological aids.
The psychologist found that the lack of use of the E-Tran, because of the
preference for high-tech tools, even though they might require greater
expertise in technology use and training, demonstrated the central role that
the everyday life context had in the use of the tools by Arianna.
Nevertheless, as prefigured during the second multidisciplinary meeting,
discontinuation of the E-Tran resulted as a consequence of Arianna‟s
maintaining strong dependence on her mother for her communicative needs,
since maternal mediation was required for the use of the most advanced
technological tools. Therefore, whereas Arianna‟s mother did not declare
any need for change in the assistive solution provided, at most complaining
of the low technological attractiveness of the E-Tran, school teachers
however expressed the need to gradually reduce supporting Arianna in the
use of tools.
The psycho-technologist‟s global evaluation stressed the opportunity to
re-propose the E-Tran and to continue the use of the scanning system
Clicker software to achieve greater autonomy. Given the outcome of the
follow-up, the psycho-technologist scheduled a new matching process with
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the user and convened the multidisciplinary team in order to describe the
new situation.
Table 2 - First cycle synoptic summary of the ATA process. In the first
column, steps A, B, and C refer to the flow chart of Figure 1
Actions of the AT Service
Delivery Centre
Professionals of the
multidisciplinary team
involved
Actions by Arianna
Step A
Contact and Data collection (1° month)
Parent request:
AT educational support;
High-tech systems for
communication.
User‟s collection data
(clinical data and medical
history):
Diagnosis: Severe spastic
quadriplegia with a dystonic
component resulted from
cerebral palsy.
ICD-9/10: G80.0.
ICF-CY: b114.1; b167.1;
s110.8; s730.4; s750.4;
d140.30; d145.30; d310.30;
d330.44; e310+4; e320+4;
e325+4; e330+4.
Vineland‟s sub-domains
under the typical score of
developmental age:
Expressive communication;
Personal and Domestic
Daily Living Skills;
Interpersonal Relationships;
Coping Skills; Gross and
Fine Motor Skills.
Good visual acuity.
Video of the Arianna‟s
behaviour in family and
school contexts.
Use of facial expressions
recognizable by caregivers
and relatives but not by
outsiders.
Arianna pointed with her
fist roughly because of low
muscle control.
She was equipped with an
electric wheelchair with a
postural system for
independent mobility.
Parents were required to fill
out the SOTU.
Step B
First Multidisciplinary Team Meeting (1° month)
Analysis of the user‟s
requests.
Analysis of the functional
profile and diagnosis.
Analysis of the individual
functioning specifically
with regard to technological
device solutions and
environmental factors
(family and school).
AT proposal for matching
Architect
Engineer
Neuro-psychometrician
Occupational therapist
Orthopedic technician
Pediatric specialized in
AT developmental
Physiatrist
Psychologist
Psycho-technologist
The SOTU score
highlighted good
predisposition for
technology use.
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process: E-Tran,
communication boards,
Clicker software, and
postural system.
Matching process (1° month)
AT proposal to the user.
User-trial.
Proposal and execution of
environmental evaluations
(family and school).
Architect
Engineer
Occupational therapist
Orthopedic technician
Physiatrist
Psychologist
Psycho-technologist
E-Tran: Control of eye
movements in a precise and
fast way.
Communication boards:
Adequate understanding of
the symbols and their
functions; difficulties in
browsing and in identifying
target locations.
Clicker software: Good
understanding of the mode
of use; Incapacity to
manage independently with
reference to time and
difficulties in maintaining
pressure on the sensor in a
consistent manner.
Second Multidisciplinary Team Meeting (2° month)
Analysis of the
environmental evaluations.
Recommendations to give
to the user:
E-Tran: Increasing the use.
Communication boards:
Reserving the use in a more
familiar and quiet
communicative setting;
Addition of symbols by the
means of the Boardmaker®
software.
Clicker software: Keeping
updated with the school
teaching units identical to
class contents.
Postural system: Placing a
sensor for automatic
scanning on the outside
right of the system.
Architect
Engineer
Neuro-psychometrician
Occupational therapist
Orthopedic technician
Pediatric specialized in
AT developmental
Physiatrist
Psychologist
Psycho-technologist
User agreement (2° month)
Team‟s proposal and user‟s
acceptance of AT matched.
Instructions for each single
device used.
Recommendations:
Warning parents of
excessive expectations on
the most technologically
Psychologist
Psycho-technologist
User manifested enthusiasm
and curiosity about ATs
proposed.
Arianna‟s caregivers
expressed higher
expectation about Clicker
software.
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advanced AT (Clicker
software).
Step C
User support and follow-up (12° month)
12-month-user-support after
the AT provision.
Follow-up meeting after 12
months of AT assigned use:
Proposal of a new ATA
cycle process to fine-tune
the first (cycle) AT
assignations.
Psychologist
Psycho-technologist
E-Tran: Never used at
home and scarcely at school
because it was viewed as
too low-tech.
Communication boards:
Used spontaneously by the
user in all environments.
Issues remained relating to
Arianna‟s independent
management of the tool.
Clicker software: Fully
managed independently.
Postural system: Addressed
the environmental issues
and met the needs of the
user in relation to the use of
technological aids.
2.3. ATA Process Second Cycle
2.3.1. Third Multidisciplinary Team Meeting (after the first Follow-Up)
for User Data Evaluation and Design of the Assessment Setting
At the multidisciplinary team meeting after the first follow-up (Figure 2,
phase 2, step [d]; Table 4, step D), the psycho-technologist chaired the team,
coordinated the professionals‟ interventions and wrote the meeting report.
The other participants included the occupational therapist and the
psychologist, in charge of the report about Arianna‟s new request. This
meeting aimed to reach greater autonomy with the high-tech tools.
With regard to AT use, the psycho-technologist proposed to the
multidisciplinary team the same technological solutions already assigned to
Arianna with just the variation of the manual scan of the Clicker software
instead of the automatic one, given the excellent performance achieved, in
order to foster greater control and speed, and enhance the user‟s
independence (Figure 1 and Table 3, step D). Then, the multidisciplinary
team charged the psycho-technologist with establishing the set-up for the
matching evaluation with the same tools of the previous evaluation with the
only change in the Clicker software, now set to automatic instead of manual
scan, and with the exclusion of the systems of posture since it did not require
any new evaluation.
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Matching Process after the first Follow-Up: Revision of the Assistive
Solution in Use. At the matching process of the second cycle (Figure 2,
phase 3, step [f]), Arianna, her mother, and her schoolteachers were present,
as well as the psychologist, the psycho-technologist, and the occupational
therapist. The latter two professionals tested the ATs for communication,
learning, and independent living. The psycho-technologist reported the
following outcomes and judgments on the matching process for each AT
tested:
About the E-Tran, albeit the pointing with eyes symbols on the
Plexiglas was clear and respected the time reading of the
communication partner, Arianna had difficulty keeping the phrase in
mind with only the vocal feedback of the interlocutor (who utters
aloud the phrase when the user is composing it by pointing with the
eyes symbols on the E-Tran).
About the communication boards reorganized, nothing significant was
noted.
About the scanning system Clicker software, set in manual mode,
Arianna understood its new scanning functioning and was able to
control upper limb movements functional to the management of the
two switches.
2.3.2. Fourth Multidisciplinary Team Meeting (after the first Follow-Up)
for Revision of the Assistive Solution
At the fourth multidisciplinary team meeting, the psycho-technologist
chaired the meeting, coordinated the professionals‟ interventions and wrote
the meeting report. The other participants included the psychologist and the
occupational therapist. On the basis of the psycho-technologist‟s report on
the matching process after the follow-up, the multidisciplinary team
identified the best assistive solution, proposing to change the ATs in use
with the following recommendations:
About the E-Tran, to increase the use of E-Tran in all contexts of life
with the aim of promoting more training to use and to write what was
communicated by Arianna in order to allow a visual cue to associate
with hearing (temporary facility).
About the communication boards reorganized, to continue in the same
manner of use.
About the scanning system Clicker software, to encourage practice
with the new manual mode setting, using activities already known by
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Arianna. To use software for educational activities already known and
the alphabetic keyboard on the screen with the aim to improve the
speed of performance and reduce the need for self-corrections.
User Agreement to the Assistive Solution Revised. The new system
proposed with the recommendations about Arianna‟s AT use was accepted
by the child, her mother, and the schoolteachers. At the same time, new
support and training were scheduled with the family for monitoring the E-
Tran and the scanning system Clicker software on manual modality use and
supporting the creation of new communication boards.
User Support and Follow-up (2). Support meetings were carried out for
another twelve months (Figure 2, phase 4, step [j]), after which a follow-up
meeting was scheduled with Arianna, her mother, and the schoolteachers
along with the psychologist and the psycho-technologist. The latter chaired
the meeting and wrote the meeting report. With regard to each AT assigned,
it emerged that (Figure 1 and Table 3, step E):
The E-Tran was used very effectively with three customized supports:
letters divided into groups, 09 numbers and mathematical symbols,
punctuation.
The Communication boards were used very little, due to poor
handling and practicality since, over time, the binder became too
large.
The manual scanning system Clicker software was managed
independently, but with critical issues (speed and number of errors)
related to user‟s motor function conditions. It was mainly used in
educational contexts for phrases with verbs and nouns. The video
keyboard was used with difficulty in timing and in the number of
errors. The boards were rarely used for communication.
The Junior postural system still continued to meet the needs of the
user well.
The psychologist found that Arianna expressed her desires with greater
determination and, because of the gradual process of social integration,
began to deal with milieus either family or school contexts that were no
longer willing to recognize her status of “uniqueness” too easily. Arianna, as
far as possible, was poised to become a child like any other child. Therefore,
the opportunity to further integrate the use of different tools and to try to
introduce the most technologically advanced solutions emerged. From a
clinical point of view, the psychologist found that while Arianna seemed to
be more independent from the mother in her communication, the mother
expressed a depressive feeling of loss regarding the special affectively
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and communicatively dyad that she‟d had with Arianna in the past. The
mother ceased to be the only interpreter of Arianna‟s needs and wishes, and
the latter was able to forge strong emotional relationships with many more
people.
The psycho-technologist‟s global evaluation highlighted the possibility of
proposing a high-tech communication system for communication and
learning. Given the outcomes of the follow-up evaluation, the
psycho-technologist scheduled a new matching process with the user and
convened the multidisciplinary team in order to describe the new situation.
Table 3 - Second cycle synoptic summary of the ATA process. In the first
column, steps D and E refer to the flow chart of the Figure 1
Actions of the AT Service
Delivery Centre
Professionals of the
multidisciplinary team
involved
Actions by Arianna
Step D
Third (after the Follow-Up) Multidisciplinary Team Meeting (13° month)
Confirmation of the same
technological solutions
already assigned in the 1°
cycle.
Variation of the manual
scan of the Clicker software
instead of the automatic
one.
Occupational therapist
Psychologist
Psycho-technologist
Matching Process after the Follow-Up (13° month)
AT proposal to the user.
User-trial.
Occupational therapist
Psychologist
Psycho-technologist
E-Tran: Arianna seemed to
have difficulties in keeping
the phrase in mind with
only the vocal feedback of
the interlocutor.
Clicker software: Arianna
understood the new
scanning functioning thanks
to the manual mode.
Step E
Fourth (after the Follow-Up) Multidisciplinary Team Meeting (14° month)
Recommendations to give
to the user:
E-Tran: Increasing the use
in all contexts of life.
Encourage to write what is
communicated to allow a
visual cue associated with
the hearing (temporary
facility).
Clicker software: Practicing
the new manual mode
setting and improve the use
of the alphabetic on-screen
Occupational therapist
Psychologist
Psycho-technologist
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keyboard to enhance the
speed of performance and
reduce the need for self-
corrections.
User agreement (14° month)
Team‟s proposal and user‟s
acceptance of AT matched.
Psychologist
Psycho-technologist
Arianna positively accepted
the proposed changes.
User support and follow-up (24° month)
12-month-user-support after
the AT provision.
Follow-up meeting after 12
months of AT assigned use:
Proposal of a new ATA
cycle process to fine-tuning
the second (cycle) AT
assignations.
Psychologist
Psycho-technologist
AT use
E-Tran: Substantial
increase of use.
Communication boards:
Used scarcely because of
poor handiness.
Clicker software: Managed
independently, but with
critical issues (speed and
number of errors) related to
user‟s motor function
conditions.
Individual functioning
Motor: Improvement in eye
gaze control for pointing at
symbols.
Communication:
Respecting the control of
social communication time.
New requests
Better integration among
devices.
A high-tech solution for
improving independence,
communication speed, and
access to digital
information.
Psychological counseling:
Arianna‟s mother reported a
depressive feeling of „loss‟
due to the increasing
independence of daughter.
2.4. ATA Process Third Cycle
2.4.1. Fifth Multidisciplinary Team Meeting (after the second Follow-Up)
for User Data Evaluation and Setting Design
At a multidisciplinary team meeting after the second follow-up, the
psycho-technologist chaired the team, coordinated the professionals‟
interventions, and wrote the meeting report. The other participants included
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the occupational therapist and the psychologist in charge to report about
Arianna‟s new requests. These were: (1) more tool integration, (2) more
advanced technology for autonomy, and (3) more psychological support in
the mother-daughter relationship.
According to the psychologist‟s report on the follow-up meeting, the
milieus of Arianna now appeared more harmonized and Arianna‟s
integration process in the school context was good enough. At this stage, it
was certainly possible to encourage greater integration of the ATs or, if
possible, a “unification, focusing on the most technologically advanced
solutions. At the same time, in order to safeguard the mother-daughter
relationship, the welfare of both and the good progress achieved by Arianna,
the psychologist suggested a path of brief counseling (6 months) to the
mother to refocus some of the issues of her emotional and existential
dimensions.
Since Arianna in the last twelve months had acquired an effective ability
to control eye gaze for pointing at symbols, the psycho-technologist
proposed to the multidisciplinary team to upgrade the E-Tran with a high-
tech solution for improving independence, communication speed, and access
to digital information (Figure 1 and Table 4, step E). Therefore, the E-Tran
could be destined to be usable just for easy and fast communicative
exchanges. Then, the multidisciplinary team charged the psycho-
technologist with the set-up (Figure 2, phase 3, step [e]) for the matching
evaluation with several eye tracking hardware and software types.
Matching Process after the second Follow-Up: Upgrade of ATs in Use.
At the matching process after the second follow-up, Arianna, her mother,
and her schoolteachers were present, as well as the psychologist and
occupational therapist. The psycho-technologist coordinated the trials and
wrote the meeting report about the outcome of the matching process. The
psychologist observed that the child seemed comfortable with the eye
tracking system; her mother and schoolteachers showed appreciation of the
characteristics and potential of the high-tech system.
The psycho-technologist and the occupational therapist tested two eye-
tracking systems. The psycho-technologist reported the following outcomes
and judgments on the matching process for each AT tested:
About the eye-tracking systems: The Eye Tech TM3 (by Eye Tech
Digital Systems) with software The Grid (by Sensory Software
International), the iAble-MyTobii (by SrLabs srl and Tobii
Technology) with the software The Grid, and the Erica System with
the LifeMate Software Suite (by Eye Response Technologies) were
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tested. Arianna understood the systems‟ functioning well and used the
custom grids made from the alphabetic keyboard and from iconic
tables. She enacted strategies of self-control and self-correction of
written words. She properly managed space, speech synthesis,
and the combined use of alphabetic and numeric keyboards, and
autonomously paused the system when needed. Arianna corrected her
own posture when reminded by the professional and independently
recalibrated the laser eye pointer.
2.4.2. Sixth Multidisciplinary Team Meeting (after the second Follow-
Up) for the Eye Tracking System Solution
At the sixth multidisciplinary team meeting (Figure 2, phase 3, step [g]),
the psycho-technologist chaired the meeting, coordinated the professionals‟
interventions, and wrote the meeting report. The other participants included
the psychologist and the occupational therapist. On the basis of the
psycho-technologist‟s report on the matching process after the second
follow-up, the multidisciplinary team identified the best assistive solution,
proposing to change the ATs in use with the following recommendations:
About the E-Tran, it should be kept for fast communication exchange,
at least until Arianna is fully autonomous in the use of the eye
tracking system.
About the eye tracking system, Arianna can use any of the tested eye
tracking systems for enriched and more complex communication than
with E-Tran. Autonomy management was suggested with the need for
oversight. When Arianna is well trained in the use of eye tracking, its
use in the school curriculum was recommended. The management
software of the eye tracking should be opened and customizable, to
meet Arianna‟s changing needs over time (e.g., The Grid by Sensory
Software International).
User Agreement to the Assistive Solution Revised. The new system
proposed with the recommendations regarding Arianna‟s AT use was
accepted by the child, her mother, and schoolteachers. At the same time,
new support and training were scheduled with the family in order to adopt
the eye tracking as the only AT for communication and learning by the next
school year.
User Support and Follow-up (3). Meetings of support were carried out
for another twelve months (Figure 2, phase 4, step [j]) after which a follow-
up meeting was scheduled in which Arianna, her mother, and the
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schoolteachers took part along with the psychologist and the
psycho-technologist. The latter chaired the meeting and wrote the meeting
report.
The psychologist found that the relationship between mother and child, at
the end of the counseling path, seemed to be evident. The mother explored
the ambivalence of her desires greater autonomy and well-being of
Arianna, on the one hand, and the need to feel needed and unique on the
other and could accept living with these two seemingly contradictory
tendencies, as long as she could recognize and sometimes distance herself
from Arianna. The process of Arianna‟s autonomy could now begin its path
without relational obstacles.
The psycho-technologist stressed the importance of continuing to support
both the family and the schoolteachers to increase the use of eye tracking.
Therefore, he provided regular support appointments with Arianna, the
family, and the schoolteachers. Between meetings, further support was
carried out at a distance, gradually integrating assistive solution identified in
upgrades and customizations that may be needed during the course of
learning and communicative autonomy of Arianna.
Ending the ATA process. The psycho-technologist verified that all the
ATs assigned were in use and met the user‟s and milieu‟s needs. In
particular, with regard to Arianna‟s functioning, improvement in eye gaze
and postural control and an improvement of communication quality, given
that she learned to respect the control of social communication time were
ascertained. Also, the factors of participation improved with the assistive
solutions provided. Arianna experienced greater autonomy and better social
integration. At this point, the psycho-technologist on behalf of the Leonarda
Vaccari Institute proposed ending the evaluation process since it was well
accepted by the utilizer and her family.
Table 4 - Third cycle synoptic summary of the ATA process. In the first
column, step F refers to the flow chart of the Figure 1
Actions of the AT Service
Delivery Centre
Professionals of the
multidisciplinary team
involved
Actions by Arianna
Step F
Fifth (after the second Follow-Up) Multidisciplinary Team Meeting (25° month)
Analysis of the new user‟s
requests.
AT proposal for matching
process: To upgrade the E-
Tran, destined for easy and
fast communicative
exchange, an eye tracking
Occupational therapist
Psychologist
Psycho-technologist
AT service delivery outcomes: a case study
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69
system was discussed.
Proposal of brief
psychological counseling
for Arianna‟s mother.
Matching process (25° month)
AT proposal of an eye
tracking system.
User-trial: EyeTech TM3,
and iAble-MyTobii, and the
Erica System were tested.
Occupational therapist
Psychologist
Psycho-technologist
User
The user was comfortable
with the eye tracking
system, enacting strategies
of self-control and self-
correction of written words.
Caregivers and
schoolteachers
Appreciation of the
characteristics and potential
of the high-tech system.
Sixth (after the Second Follow-Up) Multidisciplinary Team Meeting (26° month)
Recommendations for the
user:
E-Tran: For a faster
communicative exchange.
Eye tracking system: Its use
in the school curriculum
was recommended after a
training period.
Occupational therapist
Psychologist
Psycho-technologist
User agreement (26° month)
Team‟s proposal and user‟s
acceptance of AT matched.
Psychologist
Psycho-technologist
Arianna positively accepted
the eye tracking system.
Arianna‟s mother accepted
the psychological support.
User support and follow-up (36° month)
12-month-user-support after
the AT provision.
Follow-up meeting after 12
months of AT assigned use.
Ending the ATA process.
Psychologist
Psycho-technologist
AT use
All ATs assigned were in
use and met the user‟s and
milieu‟s needs.
Individual functioning
Motor: Improvement of eye
gaze and postural control.
Communication: Respecting
the control of social
communication time.
Participation: Improvement
of autonomy and social
integration; Maturation of
the parental relationships
also due to at the mother‟s
acceptance of Arianna‟s
autonomy.
Life Span and Disability Federici S. et al.
________________________________________________________________________________________________________________________________
70
3. Conclusions
The ATA process model guided the professionals of the Leonarda
Vaccari Institute AT Service Delivery centre and the user‟s milieu to a better
analysis and comprehension of the user‟s needs. Moreover, the effectiveness
of the ATA process was highlighted by the user‟s improvement of
autonomy, social integration and communication, and oculi-motor and
postural control. The case of Arianna stressed the role of the
psycho-technologist and the psychologist in a multidisciplinary team within
an ATA process.
The psycho-technologist is an expert in the relationship between the
person and technology and, in particular, in identifying the best available
assistive solution for a specific person in a particular context of life. The
psycho-technologist evaluates the interaction between person and
technology by following a user-AT-milieu holistic model, as in the MPT
model (Scherer, 1998, 2005), that is to say, he or she is an expert in assistive
solutions. As shown in Arianna‟s case, the psycho-technologist assumed the
role of coordinator of the multidisciplinary team, he or she was responsible
for the appropriateness of matching and follow-up assessments over time.
Furthermore, the psycho-technologist distinguishes him/herself from the
professional role of the psychologist in AT service provision, since the latter
focuses on personal factors, human relationships and communication,
connecting the “bio“, “psycho“ and “social” components affecting the ATA
process, whereas the former may not be a clinical/dynamic psychologist,
even though he or she has a background in psychology, especially in
rehabilitation (Federici, Scherer, et al., 2014).
The psychologist provides an appropriate psychological evaluation and a
precise clinical intervention with the user and/or their significant human
context over the course of the whole AT assignment process. A well-
designed AT assessment process must primarily guarantee room for the
expression of users‟ subjective dimensions and the assessment of their
human resources.
Arianna‟s case shows the contribution of the psychologist in identifying
the personal factors of the user, observing and evaluating her behavior, and
taking into account the dynamics of family relationships and the
relationships between different professionals within a multidisciplinary
team.
Finally, Arianna‟s case highlights how a comprehensive evaluation
involving key professionals over multiple points in time can yield benefits
AT service delivery outcomes: a case study
________________________________________________________________________________________________________________________________
71
above and beyond functional gains. While the time involved in conducting
such a thorough assessment and involving a multidisciplinary team may
seem to lack efficiency, such an investment can actually save time in the
long run by avoiding the need to go back and retrofit a device or gather key
information that was missed. Recent empirical evidence as stated by
Federici and Borsci (2014) interviewing 558 Italian users of four National
Healthcare System‟s AT Service Delivery centers, support the idea that
investing in the quality of AT delivery processes, by reshaping the pathways
in tune with the ATA model, may significantly decrease the likelihood of
AT non-use from more than 24% to 12% (Federici & Borsci, 2011, 2014).
When patients received an AT through a user-oriented processes of service
delivery, they experienced more benefits from the AT, experienced less
problems in daily use, and perceived a better post-assignation support from
the AT service delivery centers. The increase of both, the end-users overall
experience with the AT and relationship with the centre, results in a reduced
percentage of AT non-use. Although ATA process model shows promise
for: (1) reducing the likelihood of AT non-use; (2) improving the overall
relationship between users and professionals; and (3) increasing the
effectiveness and the quality of a delivery process, the economic and social
value of abandonment decrease can vary according to different contexts
(e.g., private or public healthcare systems).
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In this chapter, the assistive technology assessment (ATA) model has been presented. The ATA model outlines an ideal process that provides reference guidelines for both public and private centers for technical aid provision, allowing them to compare, evaluate, and improve their own matching model. The actions required by the ATA model to centers for technical aid can be divided into four fundamental steps: access to the structure and activation of the process, evaluation and activation of the aid/AT selection, delivery, and follow-up. The ATA is a user-driven process through which the selection of one or more aids/ AT is facilitated by the utilization of comprehensive clinical measures, functional analysis, and psycho-socio-environmental evaluations that address, in a specific context of use, the personal well-being of the user through the best matching of user/client and assistive solution (Scherer et al. Early Online). Because the ATA process and the MPT model and accompanying measures share a user-driven working methodology and embrace the ICF biopsychosocial model, they can be integrated within a path aiming for the best combination of AT to promote user/customer’s personal well-being.
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Background. The introduction of assistive technology (AT) into people’s lives is a deliberative and long-term process, which presupposes teamwork as much as professionalism, time, and experience. The aim of the assistive technology assessment (ATA) process is to suggest guidelines to follow in order to reach valid results during the AT selection and assignment process. Purpose. Critically discuss the application of the model of the ATA process developed by Federici and Scherer in the 2012. Method. Cross-cultural comparison of AT service delivery systems and discussion of the ATA process model adopted by Leonarda Vaccari Institute of Rome. Conclusion. Nowadays, the wide variety of AT devices on the market opens new frontiers to the individual’s enhanced functioning, inclusion, and participation. Since the choice of the most appropriate match is often a complex process, a systematic selection process such as the ATA process described in this article can help practitioners to efficiently achieve successful outcomes.
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The purpose of the present work is to present some aspects of the Assistive Technology Assessment (ATA) process model [1] compatible with the Position Paper 2012 by AAATE/EASTIN [2]. Three aspects of the ATA process will be discussed in light of three topics of the Position Paper 2012: (i) The dimensions and the measures of the User eXperience (UX) evaluation modelled in the ATA process as a way to verify the efficient and the evidence-based practices of an AT service delivery centre; (ii) The relevance of the presence of the psychologist in the multidisciplinary team of an AT service delivery centre as necessary for a complete person-centred assistive solution empowering users to make their own choices; (iii) The new profession of the psychotechnologist, who explores user’s needs by seeking a proper assistive solution, leading the multidisciplinary team to observe critical issues and problems. Through the foundation of the Position Paper 2012, the 1995 HEART study, the Matching Person and Technology model, the ICF framework, and the pillars of the ATA process, this paper sets forth a concept and approach that emphasise the personal factors of the individual consumer and UX as key to positively impacting a successful outcome and AT solution.
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Purpose: The study brings together three aspects rarely observed at once in assistive technology (AT) surveys: (i) the assessment of user interaction/satisfaction with AT and service delivery, (ii) the motivational analysis of AT abandonment, and (iii) the management/design evaluation of AT delivery services. Methods: 15 health professionals and 4 AT experts were involved in modelling and assessing four AT Local Health Delivery Service (Centres) in Italy through a SWOT analysis and a Cognitive Walkthrough. In addition 558 users of the same Centres were interviewed in a telephone survey to rate their satisfaction and AT use. Results: The overall AT abandonment was equal to 19.09%. Different Centres' management strategies resulted in different percentages of AT disuse, with a range from 12.61% to 24.26%. A significant difference between the declared abandonment and the Centres' management strategies (p = 0.012) was identified. A strong effect on abandonment was also found due to professionals' procedures (p = 0.005) and follow-up systems (p = 0.002). Conclusions: The user experience of an AT is affected not only by the quality of the interaction with the AT, but also by the perceived quality of the Centres in support and follow-up. Implications for Rehabilitation AT abandonment surveys provide useful information for modelling AT assessment and delivery process. SWOT and Cognitive Walkthrough analyses have shown suitable methods for exploring limits and advantages in AT service delivery systems. The study confirms the relevance of person centredness for a successful AT assessment and delivery process.