The Assistive Technology Assessment Process Model and Basic Definitions

Abstract

Features
Proposes an international evidence-based ideal model of the assistive technology assessment based on experimental research and experiences in assistive products service delivery
Brings together in one handbook all the assessment tools needed in an assistive technology service delivery center
Describes the professional profiles, skills, and interactions of the multidisciplinary and integrated team members involved in the assessment process
Identifies the needed role of professionals of psychotechnology and assessment
Reviews all forms of technologies, including recent technologies such as brain–computer interfaces, robotics, and exoskeletons
Comes with supplemental material containing the Matching Person and Technology tools in multiple languages.

Summary
Assistive Technology Assessment Handbook, Second Edition, proposes an international ideal model for the assistive technology assessment process, outlining how this model can be applied in practice to re-conceptualize the phases of an assistive technology delivery system according to the biopsychosocial model of disability. The model provides reference guidelines for evidence-based practice, guiding both public and private centers that wish to compare, evaluate, and improve their ability to match a person with the correct technology model. This second edition also offers a contribution to the Global Cooperation on Assistive Technology (GATE) initiative, whose activities are strongly focused on the assistive products service delivery model. Organized into three parts, the handbook: gives readers a toolkit for performing assessments; describes the roles of the assessment team members, among them the new profession of psychotechnologist; and reviews technologies for rehabilitation and independent living, including brain–computer interfaces, exoskeletons, and technologies for music therapy. Edited by Stefano Federici and Marcia J. Scherer, this cross-cultural handbook includes contributions from leading experts across five continents, offering a framework for future practice and research.

Full text

Section I
The Assistive Technology
Assessment Process Model
and Basic Denitions
Stefano Federici and Marcia J. Scherer
I.1 Introduction
As a part of the human condition, “Disability is complex, dynamic, multidimensional, and
contested” (WHO and World Bank, 2011, p. 3). “Contested” refers to difculties reaching a
consensus in dening disability. There are multiple models of disability in operations and,
often, in opposition. When talking about disability, there are many surrounding and sup-
porting issues that become relevant such as individual functioning and its measurement,
the existence of social barriers and a digital divide, objective quality of life and subjective
well-being, activity performance and participation, human rights and disparities in wealth
and health, and morbidity and mortality. Given the multidimensionality of disability, the
International Classication of Functioning, Disability, and Health (ICF) aims to make clear
that disability (and its correlated term “functioning”) must be understood as an umbrella
term, “encompassing all body functions, activities and participation” (WHO, 2001, p. 3).
CONTENTS
I.1 Introduction ............................................................................................................................ 1
I.2 The Assistive Technology Assessment Process Ideal Model ..........................................3
I.3 AT Abandonment: The Service Delivery System in Different Countries ...................... 6
I.4 Presentation of the Chapters of Section I ........................................................................... 7
I.5 Conclusion ..............................................................................................................................9
References .........................................................................................................................................9

2The Assistive Technology Assessment Process Model and Basic Definitions
Disability is a multidimensional construct, and its measurement is multidimensional
and cannot be held to a “gold standard” that is valid for all contexts and purposes (see
Chapter 2, “Measuring Individual Functioning”). The only appropriate measure is the one
that best suits the context, purpose, and person to which it is addressed, rather than the
concept of disability in the abstract. Moreover, the variety of measurement tools and the
exibility to change the measurement procedures, adapting them to different people, con-
texts, technologies and other supports, and purposes, provide the most reliable scientic
approach and clinical/practical solutions.
A well-known paradox in measuring disability arises from the fact that an individual’s
understanding of their well-being may not accord with the evaluations of medical experts
(Federici, Bracalenti, Meloni, and Luciano, 2017). Sen (2002) has noted the conceptual differ-
ence between perception and observation of health. There is often a discrepancy between
an individual’s subjective view of their health, based on personal perceptions, and the
views of doctors or professionals, which are based on objective data (Federici, Meloni, and
Corradi, 2012). Albrecht and Devlieger (1999) state that the “disability paradox” implies
that personal experience with disability is an important aspect of any assessment of dis-
ability; hence, assessments of it should combine objective observations with subjective,
self-report data.
Madans and colleagues. (2002) identify, at the aggregate level, three main classes of
reasons for measuring. Here, “providing services” (2002, slide 11)—including the devel-
opment of programs and policies for service provision and their evaluation—is the rst
among the three classes. Particularly, the Assistive Technology Assessment (ATA) process
can be viewed as one aspect of the rst-mentioned class.
Assistive Technology (AT) plays a key and fundamental role in facilitating the social
integration and participation of people with physical, sensory, communicative, and cog-
nitive disabilities. We use the term AT, except where otherwise stated, as an umbrella
term (WHO, 2004), with the meaning more commonly attributed to the “Assistive
Technology device” term, as stated by the U.S. Assistive Technology Act (United States
Congress, 2004) and acknowledged by the World Health Organization in the recent
World Report on Disability (WHO and World Bank, 2011), as follows: “Any item, piece of
equipment, or product system, whether acquired commercially, modied, or custom-
ized, that is used to increase, maintain, or improve functional capabilities of individuals
with disabilities” (p. 101). This denition stresses that what make a device an assistive
product, namely an AT, is who uses the product, rather than its intrinsic characteristics.
Thus, mainstream/everyday/universal technologies such as smartphones and robots are
considered ATs when they are used for enhancing capabilities and functioning of indi-
viduals with disabilities.
Furthermore, the International Standards Organization (ISO) has recently revised the
denition of Assistive products for persons with disability, integrating the rst denition
of 1998 (ISO 9999) with the ICF’s concepts:
“any product (including devices, equipment, instruments and software), especially
produced or generally available, used by or for persons with disability for participa-
tion, to protect, support, train, measure, or substitute for body functions, structures,
and activiies, or to prevent impairments, activity limitations, or participation restrictions”
(ISO, 2016).
According to the ISO 9999, AT is a mediator, an interface that tends to reduce the mis-
match between the person’s needs and the requests of the environment, neutralizing

3The Assistive Technology Assessment Process Model and Basic Definitions
barriers (promoting participation) and disability (reducing limitations) (e.g., ISO and IEC,
2008).
The ISO’s denition of assistive products was also discussed at the Global cooperation
on Assistive Health Technology (GATE), a WHO initiative (http://www.who.int/disabili-
ties/technology/gate/en/). GATE proposes a “positive approach” to change the denition
using a more positive wording, for example, “any product (including devices, equipment,
instruments, and software), especially designed and produced or generally available,
whose primary purpose is to maintain or improve an individual’s functioning and inde-
pendence and to facilitate participation”. In this denition, still under discussion, it is no
longer the user of a product (the person with disability) that determines whether that
product is an AT, but the purpose of use, that is, to promote well-being regardless of who
uses it. In this manner, the AT tends to coincide with a “positive technology”, the nal aim
of which is to manipulate and enhance the features of personal experience, with the goal
of increasing wellness and generating strengths and resilience in individuals, organiza-
tions, and society (Botella etal., 2012; Riva, 2013; Riva, Baños, Botella, Wiederhold, and
Gaggioli, 2012; Wiederhold and Riva, 2012).
In sum, in line with previous denitions, a product is an AT either if the user of the
product is a person with disability or if the purpose of the use enhances an individual’s
functioning, independently of the user’s traits (with or without disability).
However, in order for an AT to achieve its purpose of reducing the mismatch between
the person’s need and his/her environment and promoting well-being, a well-designed
and well-researched sequential set of assessments, administered by professionals with
relevant areas of expertise to match AT and person, is required (Scherer, 2005). The
success of the matching is strongly affected by the evaluation protocol/model, as well
as by the skills of the multidisciplinary team members (Federici and Borsci, 2016). For
this reason, Section I of this handbook provides readers with useful guidelines for
developing a set of tools for assessment of functioning and for disability screening in
centers for AT evaluation and provision (Federici, Scherer, and Borsci, 2014). The ATA
process borrows a user-driven working methodology from the Matching Person and
Technology (MPT) model of Scherer (Scherer, 1998, 2017a, b Scherer and Craddock,
2002). Furthermore, the ATA ideal model embraces the ICF biopsychosocial model
(WHO, 2001), aiming at the best combination of AT to promote the personal well-being
of customers.
I.2 The Assistive Technology Assessment Process Ideal Model
The introduction of AT into the lives of people is a thoughtful and long-term process,
which presupposes teamwork as much as professionalism, time, and experience. The aim
of the ATA ideal model is to suggest guidelines to follow in order to obtain the desired
results during the AT selection and assignment process.
This model, far from seeking to pregure a “gold standard”, instead, sought to cre-
ate a structure that allows one to build or change the existing processes so that they can
consider more personalized variables, such as the nature of the person’s disability, the
personal motivation and enthusiasm of both the person with a disability and their fam-
ily members, the social and political context, and the availability of human and nancial
resources within user-driven processes, and do so in the context of the biopsychosocial
model of the ICF.

4The Assistive Technology Assessment Process Model and Basic Definitions
The ICF (WHO, 2001) and the ICF-Children and Youth Version (ICF-CY; WHO, 2007)
provide a unied standard framework for an ATA process in the centers for AT evaluation
and provision, allowing them to seek the best match of user–AT solution, by using a com-
prehensive set of clinical measures, functional analysis (see Chapters 2 and 4), and psy-
cho-socio-environmental evaluations (see Chapter 4). By the AT solution, we mean much
more than providing a device to a person with a disability. It involves neutralizing barri-
ers, improving the functioning of individuals, and promoting their well-being (AAATE,
2003). Consequently, delivering an AT solution entails an individualized combination of
hard (actual devices) and soft (assessment, trial, and other human factors) assistive tech-
nologies, environmental interventions, and paid and/or unpaid care (Layton, Steel, and de
Jonge, 2013).
As the ATA process model is a user-driven process, any activity of the AT service deliv-
ery must nd a correspondence to a user action and vice versa. The users’ actions in the
ATA process can be grouped into three phases (Figure I.1).
User request
User actions
Request to
solve activity
limitations
Request to solve
environmental
restrictions
Providing history
(medical, rehabilitation,
support use) and
psycho-socio-
environmental data
User subjective
evaluation of
technological aid
User
evaluation
of assistive
solution
Short/long-term use
-Effectiveness
-Efficiency
-Usability
-Personal, emotional,
social, comfort with use
-Subjective well-being
-Benefit
Assistive technology obtained:
public health system or
public/private insurance
Temporary
or
permanent
EXIT
a)…
b)…
c)…
d)…
e)…
f)…
…a)
…b)
…c)
…d)
…e)
…f)
…g)
…h)
…i)
…j)
1
3
2
1
2
3
4
Start
AT service delivery
AT solution
Multidisciplinary
team evaluation
Contact
User data collection
Setting set-up
Matching process:
- Assistive solution proposal
- Assistive solution user-trial
- Assistive solution outcome
NOT
NOT
Environmental
assessment
process (see
the usability
and
accessibility
evaluation
diagram)
NOT
NOT
NOT
NOT
Exit
Assistive technology provision
User
agreement
User support
Follow-up
Multidisciplinary
team meeting for:
- User data valuation
- Setting design
Assistive technolgy assesment process
FIGURE I.1
Flow chart of ATA process ideal model in a center for AT: The ATA process ideal model can be read from the
perspective of the user or from the perspective of the center for the AT service delivery. The User Action ow
chart is on the left, and the procedures of the AT Service Delivery are on the right. The numbers refer to the
phases and the letters to the steps for each phase. (From Federici, S., Scherer, M. J., and Borsci, S. 2014. Technology
and Disability, 26(1), 27–38. doi:10.3233/TAD-140402.)

5The Assistive Technology Assessment Process Model and Basic Definitions
Phase 1 → The user seeks a solution for one or more forms of activity limitation or
participation restriction by seeking assistance from a center for AT.
Phase 2 → The user checks the solution and tries and checks one or more technological
aids provided by the professionals in a suitable evaluation setting (center, house,
hospital, school, rehabilitation center, etc.)
Phase 3 → The user adopts the solution after obtaining the assistive device(s) from the
public health system (or public/private insurance), receives training for the daily
use of the AT, and receives follow up.
The ATA process ideal model can be used by professionals to check the completeness of
the process used and to (re-)conceptualize the phases of an AT delivery system according
to the biopsychosocial model of the disability stated by the ICF (WHO, 2001). Figure I.2
displays the ICF model as it ts the ATA process model.
ICF–biopsychosocial model
Activities
AT solution
Medical
diagnoses
Body functions
and structures Partcipation
Support and
follow up
User driven
process
Start
AT service delivery
AT solution
Multidisciplinary
team evaluation
Contact
User data collection
1
2
3
4
Setting set-up
Matching process:
-
Assistive solution
proposal
-
Assistive solution
user-trial
-
Assistive solution
outcome
Assistive technology provision
User
agreement
NOT
NOT
NOT
NOT
Environmental
assessment
process (see
the usability
and
accessibility
evaluation
diagram)
Exit
User support
Follow-up
Multidisciplinary
team meeting for
- User data valuation
- Setting design
FIGURE I.2
ATA process ideal model according to the ICF’s biopsychosocial model. The biopsychosocial model is displayed
in the upper left region, and the ATA process ow chart is shown on the right. The solid line connects the com-
ponents of Body Functions and Structure with phases 1 and 2 of the ATA process: The individual functioning
and disability of the user are considered by the multidisciplinary team that evaluates the health conditions of the
user. The dashed line connects the Activities component with phase 3 of the ATA process model: The matching
process aims to support activity limitations and enhance individual functioning. The dotted line connects the
Participation component of the ICF with the Environmental assessment process and phase 4 of the ATA process.
(From Federici, S., Scherer, M. J., and Borsci, S. 2014. Technology and Disability, 26(1), 27–38. doi:10.3233/TAD-140402.)

6The Assistive Technology Assessment Process Model and Basic Definitions
I.3 AT Abandonment: The Service Delivery System in Different Countries
The most relevant studies on AT abandonment (Borg etal., 2012; Chen and Chan, 2013;
Dijcks, De Witte, Gelderblom, Wessels, and Soede, 2006; Federici and Borsci, 2011, 2016;
Federici, Meloni, and Borsci, 2016; Kittel, Di Marco, and Stewart, 2002; Kylberg, Löfqvist,
Horstmann, and Iwarsson, 2013; Löfqvist, Slaug, Ekström, Kylberg, and Haak, 2016;
Phillips and Zhao, 1993; Scherer, 1996, 2005; Scherer, Cushman, and Federici, 2004; Scherer
and Federici, 2015; Scherer, Sax, Vanbiervliet, Cushman, and Scherer, 2005; Verbrugghe
etal., 2015; Verza, Carvalho, Battaglia, and Uccelli, 2006) have been conducted in differ-
ent contexts with different national service delivery systems* (Estreen, 2010; Mathiassen,
2010; Stack etal., 2009). In some cases, such national service delivery systems have been
divided according to the model underlying the service delivery itself: medical-oriented
model, social-oriented model, or client-oriented model (Stack et al., 2009). On the other
hand, the service delivery process has been analyzed by others from the Public or Private
Health Service point of view, so that we can distinguish between private insurance, dona-
tions, and direct acquisition (Estreen, 2010; Scherer, 2017c). In Table I.1, the service delivery
systems and models of some countries are quoted, as an example from which the previ-
ously mentioned works originate:
We can observe that, in general, in European countries, a Public Health System is more
diffused where the person with a disability is considered a patient/user. Inside these
systems, the person who effects the matching does not sell AT, but acts as an intermedi-
ary between the patient/user and the AT vendors by providing an assessment and sup-
port service. In countries such as the the United States and Australia, it may occur that
the person with a disability is considered a client inside a Private System, to whom the
assessment center for AT will sell products. The rst model assures more neutrality in
assessing the best AT matching; the second model fosters user-centered satisfaction with
the best matched product. In general, when there is a Public System, the nancing of some
device categories is bound to a “prescription” and authorized by a specialist. Moreover,
the doctor who prescribes must carry out many duties that, in reality, should be within
the competence of other experts, such as engineers, psycho-technologists, psychologists,
and psychotherapists. In the Private Service, on the other hand, the client may benet
from well-prepared professionals, but without having the necessary services at their dis-
posal. Notwithstanding the diversity of service delivery systems (public/private), recent
studies prove that both systems involve high AT abandonment percentages—between
12% and 38%—with some exceptions for certain types of devices, such as electric wheel-
chairs, for which the abandonment rates can be as low as 5% (Wressle and Samuelsson,
2004). The more optional the AT use is, the higher will be the nonuse and abandonment
rate (Scherer, 2005). Moreover, both systems involve a high degree of user dissatisfaction
and a large waste of money. All this induces the scholars of this sector to pursue a critical
elaboration of ATA process models, which, starting from the modelling of the preexisting
services, allows us to develop some guidelines in order to optimize the matching process
(Ripat and Booth, 2005).
* “Service Delivery refers to professional advice and treatment activities, as well as the physical delivery of
the technical aid to the person with a disability, including training and setup if required. In the Assistive
Technology industry, the term Service Delivery is used to identify the set of facilities, procedures and pro-
cesses that act as intermediaries between the AT product manufacturers and AT end-users” (Stack etal., 2009,
p. 28).

7The Assistive Technology Assessment Process Model and Basic Definitions
I.4 Presentation of the Chapters of Section I
The chapters presented in this section aim to discuss both features and different aspects
of the ATA process ideal model, in order to set up a standard structure that can be shared
among the centers for AT that aim to reduce both the abandonment and disuse of obtained
ATs. Particularly, in Chapter 1, titled “Assessing Individual Functioning and Disability”,
the authors present an overview of the historical evolution of different models of disabil-
ity, from the medical to biopsychosocial, in order to explain the theoretical background
underlying the ATA process model. The biopsychosocial (or universal) model embraced by
the ICF is deepened here: from this novel perspective, the concepts of “functioning” and
“disability” are redened in reference to the complex interaction between personal and
environmental factors. Under the lenses of this holistic model, the authors aim to explain
the function of assistive solutions, which are conceived, here, as a mediator between the
multidimensionality of the specic health conditions of an individual and their effective
functioning in the ATA process model.
TABLE I.1
Service Delivery System and Model
Countr y Service Delivery SystemaService Delivery Modelb
Australia Private system Consumerc
Austria Public system and private system
for self-employed
Social and medical
Denmark Public system (health and
municipalities)
Social
Finland Public system (health) Medical
France Public system Medical, social, and consumer
Germany Private system and partially public
system
Medical and social
Greece Public and private system Medical and consumer
Italy Public system (health) Medical and social
Netherlands Private and public system Medical and social
Norway Public system (municipality) Medical
Spain Public system (health and social by
regions)
Social, medical, and consumer
Sweden Public system (health and county
councils and municipalities)
Medical
United Kingdom Private and public system (health
and social)
Medical, social, and consumer
United States Private system Social, medical, and consumer
Note: In almost all cases, the AT for schools in the private system is managed with a
public service delivery system.
a Survey performed between 2010 (Estreen, 2010) and 2011 by the Leonarda Vaccari
Institute in Rome, Italy.
b Stack etal. (2009)
c Free market model in which there is no intermediary between the patient/consumer
and his or her solution (Stack etal., 2009).

8The Assistive Technology Assessment Process Model and Basic Definitions
A close examination of the role of individual functioning, and how to measure it, is
presented in Chapter 2, “Measuring Individual Functioning”. The authors discuss both
issues and principles related to the measurement of individual functioning, paying special
attention to its application to the ATA process. Starting from a discussion of the complex-
ity of the denition of disability, the authors suggest different guiding principles to help
professionals working in centers for AT in choosing and applying the set of measures that
better t with the objectives of the ATA process model. Different measures for clinical,
functional, and psycho-socio-environmental factors are suggested here for the different
evaluation steps of the ATA process model. Different tools and techniques are presented
for facilitating the multidisciplinary team-building process, through the characterization
of each profession required during the assessment (and measurement) process, with the
ultimate aim of ensuring the well-being of the user.
In Chapter 3, titled “Measuring the Assistive Technology MATCH”, the problem of mea-
surement in the matching process between user and AT is discussed. In the rst para-
graph, the authors focus on the description of two models, the MPT model (Figure I.3;
Scherer, 1998, 2005) and the ICF model, in order to provide a comprehensive overview of
the main standard frameworks of measures and tools currently being used. The aim of
this study is to explain how the ATA process model is integrated with the MPT model
to achieve the best AT assistive solution, because they both share a user-driven approach
under the biopsychosocial model of the ICF.
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FIGURE I.3
(See Chapter 3, Figure 3.1; Chapter 6, Figure 6.1; Chapter 14, Figure 14.7 for the gray version). The matching
person and technology model. The “Match of Person and AT” (the smallest circle) indicates the AT solution that
increases the quality of life and well-being. (From Scherer, M. J. 2005. Living in the State of Stuck: How Technologies
Affect the Lives of People with Disabilities (4th ed.). Cambridge, MA: Brookline Books.)

9The Assistive Technology Assessment Process Model and Basic Definitions
The relations among environment, accessibility, usability, and sustainability between a
user and an AT are explained in Chapter 4, titled “Assessment of the Environments of AT
Use: Accessibility, Universal Design, and Sustainability”. In this chapter, a user experience
model and the environment evaluation model are discussed as two of the main important
steps in the ATA process model. Moreover, the Environmental Assessment in the ATA
process is both introduced and exemplied as a step-by-step decision-making process, set
up by the multidisciplinary team for collecting data about the environment(s) of use, in
which the users put the AT to work.
Chapter 5, titled “Measuring the Impact of AT on Family Caregivers”, concludes this
section. It provides an overview of the literature about the impact of AT on informal care-
givers of children and adults, and describes the relationship between the outcomes for
assistance users, their informal caregivers, and the related assistive solutions. This chapter
aims both to provide recommendations for practice and to suggest future developments in
this eld through two hypothetical illustrative vignettes.
I.5 Conclusion
The AT Assessment is a user-driven process through which the selection of one or more
ATs for an AT solution is facilitated by the comprehensive utilization of clinical measures,
functional analysis, and psycho-socio-environmental evaluations that address, in a spe-
cic context of use, the personal well-being of the user through the best matching of user and
AT solution. As the AT solution represents the outcome of a user-driven process aimed at
the improvement of individual functioning, it can be considered as a mediator of quality of
life and well-being in a specic context of use. For these reasons, it is important to under-
score that the AT solution does not coincide with a technology product, because the former
is a complex system in which psycho-socio-environmental factors and assistive technol-
ogy interact in a nonlinear manner, by reducing the activity limitations and participation
restrictions through one or more technologies.
The denition of ATA represents the core denition of this handbook, summarizing the
properties of the ATA process model. All the chapters in Section I refer to this denition
and follow a guiding reference model, which is presented in Figure I.1.
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