Principles and Practice
SECOND EDITION
Albert M. Cook, PhD, PE
Professor and Dean, Faculty of Rehabilitation Medicine
Susan M. Hussey, MS, OR
Coordinator and Professor, Occupational
ASSISTIVE TECHNOLOGIES: A WORKING DEFINITION Definition of Assistive Technology Devices and Services Characterization of Assistive Technologies Assistive versus rehabilitative or educational technologies Cow to high technology Hard and soft technologies Appliances versus tools Minimal to maximal technology General versus specific technologies Commercial to custom technology Summary
A HISTORICAL PERSPECTIVE ON ASSISTIVE TECHNOLOGY DEVICES AND SERVICES (Very) Early Developments in Assistive Technologies Evolution of State‑of‑the‑Art Assistive Technology Federal Legislation Affecting the Application of Assistive Technologies Rehabilitation Act of 1973 (Amended) Individuals with Disabilities Education Act Amendments of 1997 Assistive Technology Act of 1998 The Developmental Disabilities Assistance and Bill of Rights Act Americans with Disabilities Act (ADA) of 1990 Medicaid Early Periodic Screening, Diagnosis and Treatment Program
Medicare
THE ASSISTIVE TECHNOLOGY INDUSTRY TODAY The Consumer and Direct Consumer Services The consumer Characteristics of direct consumer service programs Basic Research Applied Research Product Development Manufacturing Distribution of Hard Technologies Information and Referral Education
PROFESSIONAL PRACTICE IN ASSISTIVE TECHNOLOGY Providers of Assistive Technology Services Ethics and Standards of Practice A code of ethics for assistive technologies: the RESNA Code of Ethics Standards of practice Quality Assurance Overview Standards for service providers Standards for devices outcomes of assistive technology delivery
SUMMARY
Upon completing this chapter, you will be able to:
1. Define assistive technology 2. Delineate the characteristics of assistive technologies 3. Describe the history of assistive technology practice 4. List the major legislative initiatives that have affected the application of assistive technologies 5. Describe the components of the assistive technology industry 6. Explain the roles of the consumer
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7. Identify several distinguishing features of service delivery programs
8. Identify the professionals who may work as assistive technology practitioners
9. Understand the transdisciplinary approach to assistive technology service delivery
10. Discuss the major professional issues in assistive technology practice
Activity Alpha Testing Assistive Technology Assistive Technology Practitioner (ATP) Assistive Technology Service Assistive Technology Supplier Beta Testing
Consumer of Assistive Technologies Device Direct Consumer Services Disability Handicap Impairment Least Restrictive Environment
Participation Prototype Quality Assurance Reasonable Accommodation Telerehabilitation Transdisciplinary Team Approach Universal Design
In the last 15 to 20 years there has been major growth in
the application of technology in ameliorating the problems of persons with
disabilities. Despite this growth, no unified set of principles for this
application of technology has emerged, and one of the major goals of this text
is to develop this set of principles. We begin in this chapter by providing an
overview of assistive technologies and the industry that supports their
development: and distribution. We also present a brief historical perspective
and a summary of the major
in the document titled International Classification of Impairments, Disabilities and Handicaps (ICIDH), the World Health Organization (WHO) defines an impairment as "any loss or abnormality of psychological, physical or anatomical structure or function." A disability results when the impairment leads to an inability to "perform an activity in the manner or within the range considered normal for a human being" (e.g., difficulties in communicating, hearing, moving about, or manipulating objects). A handicap results when the individuals with an impairment or disability is unable to fulfill his or her normal role. According to these definitions, a handicap is not a characteristic of a person; it is a description of the relationship between the person and the environment (World Health Organization, 1980). For example, an individual who is born without both upper extremities (the impairment) may not be able to write or complete self‑care tasks in the normal fashion (the disability). If this person is prevented from participating in school or being em
ployed by this impairment and disability, this is a handicap. In spite of this impairment, this individual may perform daily activities using his or her feet or mouth or may use prosthetic devices in order to overcome a handicapping condition. This approach, which shifts the handicap from the individual to the environment, provides an important perspective an the role of assistive technologies in reducing the handicapping effects of disabilities. Describing persons with disabilities in this way also emphasizes functional outcomes, instead of focusing on limitations, and assistive technologies are employed primarily to contribute to successful functional outcomes for persons with disabilities.
The WHO revised the original ICIDH into a new format titled ICIDH‑2: International Classification of Functioning, Disability and Health‑ICF (World Health Organization, 2001). This new framework substitutes activity for disability and participation for handicap. These terms are precisely defined in the ICIDH‑2 guidelines in ways that differ from their everyday meanings. Developed in response to worldwide concern for the limitations of the original ICIDH, the new terminology has several benefits. First of all it recognizes that the limitations presented by an impairment are reflected in both the restrictions placed on the person's activities and in the barriers to participation created by society. The impairment, activity, and participation categories are viewed as distinct but parallel classifications. The ICIDH‑2 document defines impairment as a loss or abnormality of body structure, physiology, or psychological function. Activity is the "execution of a task or action by an individual" (World Health Organization, 2001, p. 15). Participation is defined as "involvement in a life situation" (World Health Organization, 2001, p. 15). Contextual factors are referred to as environmental or personal. The latter are internal to the person and have an
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impact on how disablement is experienced. Examples include gender, age, other health conditions, fitness, lifestyle education, and similar factors. Environmental contextual factors are outside the individual (e.g., attitudes of society, architectural barriers, and legal factors). Both types of contextual factors can be influenced by assistive technologies, and Chapter 2 presents a model that includes these considerations. The ICF has great potential for influencing social policy, legislation, service delivery, and research in disability and assistive technologies. Fougeyrollas and Gray (1998) discuss the value of classification schemes like the ICIDH‑2 and their implications for assistive technologies.
Dictionaries provide the following definition of technology:
(1) The science or study of the practical or industrial arts, (2) applied science, (3) a method, process, etc. for handling a specific technical problem (McKechnie, 1983; Guralnik, 1979]
Surprisingly, none of these definitions says anything about a "device"; instead the emphasis is on the application of knowledge. This is an important concept, and we shall use the term assistive technology to refer to ,a broad range of devices, services, strategies, and practices that are conceived and applied to ameliorate the problems faced by individuals who have disabilities.
Within this framework there are many ways to define
assistive technologies. One widely used definition is that provided in Public
Law (PL) 100‑407, the Technical Assistance to the States Act in the
Any item, piece of equipment or product system whether acquired commercially off the shelf, modified, or customized that is used to increase, maintain or improve functional capabilities of individuals with disabilities.
This definition has several important components, and because we plan to use it as a working definition throughout this book, we need to examine these in some detail. First, the definition includes commercial, modified, and customized devices. By including all types of devices, we encompass an extremely wide range of applications. Second, this definition emphasizes functional capabilities of individuals with disabilities. Functional outcomes are the only real measure of the success of assistive technology devices, and throughout this text we stress the importance of providing technologies that result in increased functional capability. Finally,
the emphasis on individual persons with disabilities underscores the importance of treating each application of technology as a unique circumstance. No two applications are exactly the same in terms of the needs and skills of the person being served, the activities to be accomplished, and the context in which the application takes place.
Public Law 100‑407 also defines an assistive technology service as
any service that directly assists an individual with a disability in the selection, acquisition or use of an assistive technology device.
The law also includes several specific examples that further clarify this definition. These include (1) evaluating needs and skills for assistive technology; (2) acquiring assistive technologies; (3) selecting, designing, repairing, and fabricating assistive technology systems; (4) coordinating services with other therapies; and (5) training both individuals with disabilities and those working with them to use the technologies effectively. This definition demonstrates the broad spectrum of services inherent in the delivery of assistive technologies.
In this section we present a characterization of assistive technologies from several points of view. Each of these is a logical outgrowth of the definitions presented earlier, and each is useful in the process of applying assistive technologies. Box 1‑1 shows several classifications used to distinguish different types of assistive technologies.
Assistive versus rehabilitative or educational technologies. Technology can serve two major purposes: helping and teaching (Smith, 1991). Technology that helps an individual to carry out a functional activity is termed assistive technology. Our emphasis in this text is on assistive technologies that serve a variety of functional needs. Technology
Box 1‑1 Characterizations of Assistive Technologies
Assistive versus rehabilitative or educational technologies Cow to high technology Hard technologies and soft technologies Appliances versus tools Minimal to maximal technology General versus specific technologies Commercial to custom technology
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can also be used as part of an educational or rehabilitative process. In this case the technology is usually used as one modality in an overall education CT rehabilitation plan. Technology in this sense is used as a tool for remediation or rehabilitation rather than being a part of the person's daily life and functional activities, and we refer to it as rehabilitative or educational technology, depending on the setting. Often rehabilitative or educational technology (e.g., cognitive retraining software) is employed to develop skills for the use of assistive technologies, and we discuss some of these applications in later chapters.
Low to high technology. The next of these distinctions is between low‑technology devices and high‑technology devices. Although this distinction is; imprecise, we often describe inexpensive devices that are simple to make and easy to obtain as "low" technology and devices that are expensive, more diffcult to make, and harder to obtain as "high" technology. According to this distinction, examples of low‑technology devices are simple pencil and paper communication boards, modified eating utensils, and simple splints. Wheelchairs, electronic communication devices, and computers are examples of high‑technology devices.
Hard and soft technologies. Odor (1984) has distinguished between hard technologies and soft technologies. Hard technologies are readily available components that can be purchased and assembled into assistive technology systems. This includes everything from simple mouth sticks to computers and software. The PL 100‑407 definition of an assistive technology device applies primarily to hard technologies as we have defined them. The main distinguishing feature of hard technologies is that they are tangible. On the other hand, soft technologies are the human areas of decision making, strategies, training, concept formation, and so on. Soft technologies are generally captured in one of three forms: (1) people, (2) written, and (3) computer (Bailey, 1989). These aspects of technology, without which the hard technology cannot be successful, are much harder to obtain. Assistive technology services as defined in PL 100‑407 are basically soft technologies. Soft technologies are difficult to acquire because they arc. highly dependent on human knowledge rather than tangible objects. This knowledge is obtained slowly through formal training, experience, and textbooks such as this one. The development of effective strategies of use also has a major effect on assistive technology system success. Initially the formulation of these strategies may rely heavily on the knowledge, experience, and ingenuity of the assistive technology practitioner. With growing experience, the assistive technology user originates strategies that facilitate successful device use. The roles of both hard and soft technologies as integral portions of assistive technology systems is discussed in the section on activities in Chapter 2.
Appliances versus tools. An appliance is a device that "provides benefits to the individual independent of the individual's skill level" (Vanderheiden, 1987, p. 705). Tools, on the other hand, require the development of skill for their use. Household appliances such as refrigerators do not require any skill to operate, whereas tools such as a hammer or saw do require skill. This same criterion applies to assistive technologies. The determining factor in distinguishing a tool from an appliance is that the quality of the result obtained using a tool depends on the skill of the user. For example, eyeglasses, splints, a seating system, or a keyguard for a computer are all appliances, since the quality of the functional outcome does not depend on the skill of the user. On the other hand, success in maneuvering a powered wheelchair does depend on the skill of the user; therefore the wheelchair is classified as a tool. Examples of assistive technology tools and appliances are shown in Table 1‑1.
In some instances the device may be a tool or an appliance, depending on how it is set up to be used. For example, an environmental control system that controls lights or appliances (see Chapter 11) requires a relatively complex set of electronic circuits that most would agree are high tech. However, this system can be set up so that the only skill required to operate it is to turn it on or off, in which case it may be considered an appliance. In other instances this system may require the user to learn a sophisticated method of scanning in order to operate it; the system would then be considered a tool. It is important to note that an appliance that requires user skill because it is poorly designed is not considered a tool.
As Vanderheiden (1987) points out, the successful use of assistive technology tools requires training, strategies, and special skills. These are soft technologies. For example, learning aids that facilitate the use of an assistive device are tools that are employed only until the user gains sufficient skill to use the device independently. However, the use of the learning aid requires skill, and this aid is therefore a tool.
Examples of Assistive Technology Tools and Appliances
|
Topic (Chapter) |
Appliances |
Tools |
|
Control interfaces (7) |
Keyguards |
Joystick |
|
Computer access (8) |
Enlarging lens |
Enlarged keyboard |
|
Augmentative communication (9) |
Alphabet board |
Manipulation (11) |
|
Environmental control* |
Electric feeder |
Mobility (10) |
|
Wheelchair armrest |
Manual wheelchair push rims |
Sensory (12) |
|
Eyeglasses |
Long cane |
|
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Strategies for the use of an assistive device require skill and are therefore properly categorized as tools. Both appliances and tools require careful assessment, recommendation, and fitting (see Chapter 4), but only the tool also requires skill development (Vanderheiden, 1987). If we include training of care providers, as well as the consumer of the technology, then training also may be necessary for appliances. For example, when a new seating system is provided (Chapter 6), the care staff must be trained in how to position the person in the seating system. By including soft technologies in our concept of a tool, we emphasize the importance of developing these skills together with the acquisition of the basic hard technology tool or appliance.
Another important point raised by Vanderheiden (1987) is that the tools used by persons with disabilities are often different from those used by the general population. This means that, in order to develop skill, the assistive technology user often cannot observe someone using the same device. People routinely use observation, such as watching someone using a hammer, as a means of learning how to use a tool. When the person with a disability is the only one in that environment who is using the tool, he or she must rely more heavily on personal experience and formal training to learn to use it effectively.
Minimal to maximal technology. Assistive technologies are specified and designed to meet a continuum of needs. At one extreme are devices that provide some assistance or augment the individual's ability to perform a task. For example, an individual with cerebral palsy may be able to speak, but on occasion his speech may be difficult to understand. In those instances the individual may clarify his speech using a letter board to spell out words not understood. Or a person with respiratory problems may be able to ambulate inside her house but, because of low endurance, may require a powered wheelchair to be able to do her grocery shopping independently. In fact, many grocery stores now provide powered carts for individuals who need this type of augmented mobility. At the other extreme are assistive technologies that replace significant amounts of ability to generate functional outcomes. For example, some individuals have no verbal communication ability and may require a device to be able to communicate. Likewise, some individuals are totally dependent on a manual or powered wheelchair for their personal mobility.
Minimal technologies generally augment rather than replace function. Classically, devices that augment have been termed orthoses or orthotic devices. Although this term originally referred to braces of various types, it has been broadened to include all devices that assist or augment function. The term prosthetics or prosthetic device originally was used to describe devices that replaced a body part both structurally and functionally. Now this term has also been broadened to include all devices that provide a functional
replacement. For example, augmentative communication systems that replace the function of speech are sometimes called speech prostheses.
General versus specific technologies. We differentiate between assistive technologies that are used in many different applications as general technology and those that are intended for a specific application. General‑purpose assistive technologies include (1) positioning systems, (2) control interfaces, and (3) computers. These are classified as general purpose because they are used across a wide range of applications. Body position affects the way an individual uses the assistive technology. Frequently, external support systems, an assistive technology, are necessary to achieve a body position that facilitates functional activities. Control interfaces are the means by which the user interacts with any assistive technology. Examples include the joystick on a powered wheelchair, the keyboard on a computer, or the handle that operates the closing mechanism on a reacher. Virtually every electronic assistive technology has a computer incorporated into it. This enhances the flexibility and the breadth of application of these devices. Thus we also include computers as general‑purpose technologies.
Speck purpose assistive technologies facilitate performance in one unique application area. Examples include devices for communication, manual and powered wheelchairs, feeding devices, hearing aids, and mobility aids for persons with visual impairments. Because these devices are intended for a specific use, it is possible to design them to maximize their capabilities to meet a particular need.
Commercial to custom technology. Another distinction shown in Box 1‑1 is between commercially available devices and those that are custom made for an individual person. There is actually a continuum from commercial devices (designed for the general public and designed for persons with disabilities), to modification of a commercial device, and finally to making a completely customized device.
Figure 1‑1 illustrates the progression from commercially available devices to those that are completely customized for an individual. We use the term commercially available to refer to devices that are mass produced. These include commercial devices designed for the general population (standard commercially available devices) and assistive technologies (special commercially available devices), which are mass‑produced devices designed for individuals with disabilities. For example, standard personal computers designed for the general population are often used by persons with disabilities. Increasingly, commercial products are being designed according to the principles of universal design: the design of products and environments to be usable by all people, to the greatest extent possible, without the need for adaptation or specialized design (NC State
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Box 1‑2 Principles of Universal Design
ONE: EQUITABLE USE
The design is useful and marketable to people with diverse abilities.
TWO: FLEXIBILITY IN USE The design accommodates a wide range of individual preferences and abilities.
THREE: SIMPLE AND INTUITIVE USE
Use of the design is easy to understand, regardless of the user's experience, knowledge, language skills, or current concentration level.
FOUR: PERCEPTIBLE INFORMATION
The design communicates necessary information effectively to the user, regardless of ambient conditions or the user's sensory abilities.
FIVE: TOLERANCE FOR ERROR
The design minimizes hazards and the adverse consequences of accidental or unintended actions.
SIX: LOW PHYSICAL EFFORT The design can be used efficiently and comfortably and with a minimum of fatigue.
SEVEN: SIZE AND SPACE FOR APPROACH AND USE
Appropriate size and space is provided for approach, reach, manipulation, and use regardless of user's body size, posture, or mobility.
University, The Center for
Universal Design, 1997). In this approach, features that make a product more
useful to persons who have disabilities (e.g., larger knobs; a variety of
display options‑visual, tactile, auditory; alternatives to reading text‑icons,
pictures) are built into the product. This is much less expensive than
modifying a product after production to meet the needs of a person with a
disability. In some cases (e.g., telecommunications equipment) this universal
design approach is mandated by federal regulations. In some countries,
universal design is known as "design for all." The
When an individual's needs for assistive technology cannot be met with a commercial device, we attempt to use special devices that are mass produced and commercially
Figure 1‑1 This diagram shows the progression from commercially
available devices for the general population and commercially available devices for special populations to modified devices and custom devices.
available for persons with disabilities. Examples include wheelchairs, augmentative communication systems, and many aids to daily living. In some cases a combination of standard and special‑purpose technologies are used; this is represented by the crosshatched area of Figure 1‑1. For example, a standard general‑purpose computer may be used with special‑purpose software to create an augmentative communication device (see Chapter 9).
If commercially available devices cannot meet an individual's needs, we may modify it. This modification can vary from simple to very complex. For example, if an individual has difficulty using the keys on a computer keyboard, we can purchase software that facilitates its use. In this case the most expensive and complex part of the system (the computer) is a standard commercial product, and the software is the simplest and least expensive portion of the system. However, the software may have a cost that is much higher than expected relative to its simplicity because it is a special product and all the costs of development must be recovered from the small production run. A special commercially available device may be modified as well. For example, a commercially available augmentative communication device may require modification so that it can be mounted on a user's wheelchair.
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When no commercial device or modification is appropriate, it is necessary to design one specifically for the task at hand. This approach results in a custom device. Because they are mass produced, commercial devices have a lower per unit cost than do custom devices. For example, seating and positioning systems for persons with severe disabilities are often individually contoured to achieve the necessary functional result, and this can increase the cost (;see Chapter 6).
Another important difference between modified or custom devices and commercial devices is the level of technical support that is available with each. A commercially produced device generally has written documentation and operator's manuals available. Although the quality of these written materials varies widely, some documentation is better than none, and modified or custom devices often have none. The manufacturer or supplier of commercial equipment provides technical support and repair. Because modified or custom devices are one of a kind, technical support may be hard to obtain, especially if the original designer and builder is no longer available (e.g., if the user moves to a new area).
Assistive technology can be characterized in many ways. It is useful to realize, however, that yesterday's high tech is tomorrow's low tech, custom devices become commercial if more than a few people need them, and appliances often enable the use of tools. Thus no good categorization is perfect or is static. As the field advances, there will be new considerations that will further stretch our concepts and force new ways of categorizing and describing assistive technologies.
Although it is tempting to view assistive technologies and the assistive technology industry as innovations that have occurred over the past 20 years, we must go back much further in time to really investigate the origins of this field. Imagine that we are in the Stone Age. Our :friend Borg has broken his leg on a hunting expedition. Because there is no plaster yet available, his leg is not placed in a plaster cast, and when it heals he has a decided limp. Determined to continue providing for his clan, he reaches for the nearest stick to assist his walking. Thus one of the first assistive technology devices is conceived, fabricated, and put into use. At the time this custom device is referred to as "high tech" because of its advanced design and its use of state‑of‑the‑art materials. As time moves on, Borg's descendants begin to
realize that assistive technologies
can help meet other needs. His great granddaughter,
Assistive technologies have always been based on the materials and state‑of‑the‑art technology available to the practitioners. In assistive technologies we emphasize functional outcomes above all other considerations. For this reason, some applications have had little change for many years. Borg's cane is one example; although the structure has remained the same, the materials have changed. However, other applications have only been possible as technologies have advanced.
During the Civil War in the
Miniature electronic circuits only available in the past 20
years have replaced
In some cases, current assistive technology applications were not possible as few as 15 years ago. The welldocumented revolution in electronics is the reason for most
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of these gains, and computers are the vehicle by which the advancements have been made. The single most important change in computer design and construction was the reduction in complexity brought about by the development of the microprocessor electronic circuit "chip." This innovation, the microprocessor, resulted in reduced size (from a room full of electronics to a typewriter‑sized device), reduced cost (affordable by an individual), and greatly increased functional capabilities. Whereas we normally, think of computers as stand‑alone personal systems, microprocessors are built into a large number of devices, from computer printers to microwave ovens and other household appliances. These chips also make possible such important innovations as synthesized speech (see Chapters 8, 9, and 12), robotic aids (see Chapter I1), and computer graphics, all of which play major roles in assistive technology applications. It is difficult to find assistive technology applications in any functional performance area that have not been affected by microcomputer advances. Even in the area of seating and positioning, computer technology is being used for the design and manufacture of custom seat cushions (see Chapter 6). Throughout the remainder of this text we describe the most important of these applications.
Whereas industrial advancements and competition have driven
the recent development of assistive technology devices, the development of
assistive technology services and service delivery in the
Rehabilitation Act of 1973 (Amended). The Rehabilitation Act establishes several important principles on which subsequent legislation has been based. One of the most important of these is the concept of reasonable accommodation in employment and in secondary education. The act mandates that employers and institutions of higher education receiving federal funds seek to accommodate the needs of employees and students who have disabilities. It
specifically prohibits discrimination in employment or admission to academic programs solely on the basis of a disability. This law originally described both reasonable accommodation and least restrictive environment (LRE), a term relating to the degree of modification that is acceptable in a job or academic program.
As a result of the Rehabilitation Act of 1973, many employers and universities made architectural changes to campuses and work settings to reduce barriers. Elevators were added to buildings, ramps and curb cuts were made to accommodate wheelchair users, and voice and Braille labels were added to signs (including elevators) to provide access for visually impaired persons. Many of the efforts to achieve accommodation in the least restrictive environment involved the use of assistive technologies.
The Rehabilitation Act Amendments of 1998, which are contained in the Workforce Investment Act of 1998 (PL 105‑220), are the most recent amendments to the Rehab Act. This act was also amended in 1986 (PL 99‑506), 1992 (PL 102‑569), and 1993 (PL 103‑73). Together they include several provisions involving assistive technology. First the amendments require that each state include within its vocational rehabilitation plan a provision for assistive technology (referred to in PL 99‑506 as rehabilitation engineering or technology and in PL 105‑220 as rehabilitation technology). PL 99‑506 defined rehabilitation engineering as
the systematic application of technologies, engineering methodologies, or scientific principles to meet the needs of and address the barriers confronted by individuals with handicaps in areas which include education, rehabilitation, employment, transportation, independent living and recreation (Enders and Hall, 1990, p. 460).
Because this plan is the basis by which states receive federal funding for vocational rehabilitation, there is a strong incentive to provide these technology‑related services. The Rehab Act also requires that provision for acquiring appropriate and necessary assistive technology devices and services be included in Individualized Written Rehabilitation Programs (IWPs), which are written for individuals with disabilities.
An important provision of the Rehab Act is Section 508. First added in the 1986 amendments and later strengthened in the 1998 amendments, this section was developed to ensure access to "electronic office equipment" by persons with disabilities who work for the federal government. Although limitation to the federal government may seem to be so restrictive as to severely reduce the impact of the regulations, the federal government is such a large purchaser of computers and other office technology that any purchasing specifications it makes take on the role of informal standards. This legislation has had a significant impact on the design and manufacture of computers and their accessibility to persons with disabilities. Persons who are blind or
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Recent Major U.S. Federal Legislation Affecting Assistive Technologies
|
Legislation |
Major Assistive Technology Impact |
|
Rehabilitation Act of 1973, as amended |
Mandated reasonable accommodation and LRE in federally funded employment and higher education; requires both assistive technology device and services be included in state plans and IWRP for each client; Section 508 mandates equal access to electronic office equipment for all federal employees; defines rehabilitation technology as rehabilitation engineering and assistive technology devices and services; mandates rehabilitation technology as primary benefit to be included in IWRP |
|
Individuals with Disabilities Education Act Amendments of 1997 |
Recognized the right of every child to a free and appropriate education; included concept that children with disabilities are to be educated with their peers; extended reasonable accommodation, LRE, and assistive technology devices and services to age 3-21 education; mandated IEP for each child, to include consideration of assistive technologies; also included mandated services for children from birth to 2 and expanded emphasis on educationally related assiistive technologies |
|
Assistive Technology Act of 1998 (replaced Technology Related Assistance for Individuals with Disabilities Act of 1988) |
First legislation to specifically address expansion of assistive technology devices and services; mandates consumer-driven assistive technology services, capacity building, advocacy activities, and statewide system change; supports grants to expand and administer alternative financing of assistive technology systems |
|
The Developmental Disabilities Assistance and Bill of Rights Act |
Provides grants to states for developmental disabilities councils, university-affiliated programs, and protection and advocacy activities for persons with developmental disabilities; provides training and technical assistance to improve access to assistive technology services for individuals with developmental disabilities |
|
Americans with Disabilities Act ( |
Prohibits discrimination on the basis of disability in employment, state and local government, public accommodations, commercial facilities, transportation, and telecommunications, all of which affect the application of assistive technology; use of assistive technology impacts requirement that Title II entities must communicate effectively with people who have hearing, vision, or speech disabilities; addresses telephone and television access for people with hearing and speech disabilities |
|
Medicaid |
Income-based ("means-tested") program; eligibility and services differ from state to state; federal government sets general program requirements and provides financial assistance to the states by matching state expenditures; assistive technology benefits differ for adults and children from birth to age 21; assistive technology for adults must be included in state's Medicaid plan or waiver program |
|
Early Periodic Screening, Diagnosis and Treatment Program |
Mandatory service for children from birth through age 21; includes any required or optional service listed in the Medicaid Act (see plan |
|
Medicare |
Major funding source for assistive technology (durable medical equipment); includes individuals 65 or over and those who are permanently and totally disabled; federally administered with consistent rules for all states |
have low vision and those with difficulty in accessing the keyboard have benefited from standards derived as a result of Section 508, and several manufacturers have included in the basic designs of their computer systems technology that increases access. Many of these features are discussed further in Chapter 8.
The major intent of Section 508 is that electronic and information technology developed, procured, maintained, or used by the federal government be accessible; to people with disabilities. Section 508 applies to federal departments and agencies. It covers access to electronic office equipment and electronic information services provided to the public by the federal government. This includes ensuring; that end users with disabilities (1) have access to the same databases and application programs as other end users, (2) are supported in manipulating data and related information resources to attain equivalent end results as other end users, and (3) can
transmit and receive messages using the same telecommunication systems as other end users. The U.S. Architectural and Transportation Barriers Compliance Board is now developing standards for Section 508. The guidelines accompanying Section 508 also detail the functional performance specifications for electronic office equipment accessibility. Because of provisions in the former Tech Act, now the Assistive Technology (AT) Act of 1998 (see p. 12), states and territories that receive AT Act funding and all subrecipients must comply with Section 508.
Individuals With Disabilities Education Act Amendments of 1997. The Individuals with Disabilities Education Act Amendments of 1997 (IDEA 97), PL 105‑17, recognized the right of every child with a disability to receive a "free and appropriate public education" (FA‑PE). This right to a public education was initially legislated under
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the Education for All Handicapped Children Act (EHA; PL 94‑142), which was first passed by Congress in 1975. Before this law, more than 1 million children with disabilities were excluded from American public schools. Currently there are approximately 6 million children being served under IDEA.
IDEA includes the concept that children with disabilities are to be educated with their nondisabled peers to "the maximum extent appropriate." Children with disabilities are to be segregated or otherwise removed from the regular classroom "only when the nature or severity of the handicap is such that education in regular classes . . . cannot be achieved." Under the requirements of this law, an individual education program (IEP) must be written for each student. The IEP "sets out the child's present educational performance, establishes annual and short‑term objectives for improvements in that performance, and describes the specially designed instruction and services that will enable the child to meet the objectives."
Special education, under IDEA, is defined as "specifically designed instruction . . . to meet the unique needs of a child with disabilities with the necessary supplementary aids and related services" needed for the child to benefit from educational services in the least restrictive environment. The 1997 amendments to IDEA stated that the goals of IDEA 97 are to make education of children with disabilities more effective through the following steps:
1. Strengthening the role of parents and fostering partner ships between parents and schools
2. Increasing expectations and ensuring access to the general curriculum to the maximum extent possible
3. Aligning Part B programs (those for children ages 3 to 21) with state and local improvement efforts so that students with disabilities benefit from them
4. Providing whole‑school approaches and prereferral intervention to reduce the need to label children to address their learning needs
5. Focusing resources on teaching and learning and reduc ing paperwork burdens
6. Supporting high‑quality, intensive professional development for all personnel working with children with disabilities
IDEA 97 includes positive changes regarding assistive technology. The assistive technology needs of a child with disabilities must be "considered" along with other special factors by the IEP team in formulating the child's IEP.
The terms assistive technology devices and assistive technology services were first included in IDEA. in 1991. The definitions of "assistive technology device" and "assistive technology service" were the same as those found in the 1988 Technology Related Assistance for :Individuals with Disabilities Act (Tech Act; PL 100‑407). A policy statement on the right of a student with a disability to receive
assistive technology under PL 94‑142 was issued on August 10, 1990, by the federal Office of Special Education Programs (OSEP) (Button, 1990). This policy statement outlines a wide range of services and devices that may be included in an IEP and describes the process of developing the IEP to include them. Button presents guidelines to parents in the development of an appropriate IEP involving the use of assistive technologies. Desch (1986) describes the implications of PL 94‑142 regarding the acquisition of assistive technologies by children with disabilities. The impact of this law has been far reaching. Devices ranging from sensory aids (visual and auditory) to augmentative communication devices to specialized computers have been utilized to provide access to educational programs for children with disabilities. Lack of local services or lack of funds are not sufficient reasons to deny services or devices justified in the IEP. If the IEP goals are not met, or if there are differences over what should be included in the IEP, there is a fair hearing process that may be pursued. IDEA also mandated that local educational agencies be responsible for providing assistive technology devices and services if these are required as part of the child's educational or related services or as a supplementary aid or service.
The focus of IDEA 97 is on improving results for children with disabilities. One major portion of the original act invited states to expand and improve services to infants and toddlers with disabilities and their families (Part H, the Infants and Toddlers with Disabilities Program). In 1997 Part H became Part C of IDEA 97.
Part C of IDEA 97 provides for services to infants and toddlers (birth through age 2). More than 177,000 children receive services under Part C, and of those, nearly 10,000 receive assistive technology devices and services. State AT Act projects have been active in promoting the use of assistive technology for the very young and have contributed to building the capacity to provide AT services under Part C. Technology provided includes battery‑operated toys with easy‑access switches, seating and positioning systems, computers and alternative access aids, communications software, and others. Adapted toys help the child learn the basic concept of cause and effect. Seating and positioning systems provide support and guide the growth of a child's body. They also allow the child to move about in his or her environment. Computers and alternate access aids, such as large keypads and touch screens, can help children use software that develops communication, perceptual skills, fine motor skills, and many other skills. Through annual grants beginning in 1987, financial support is provided to develop, establish, and maintain a statewide system that offers early intervention services to all eligible children. Although participation in Part H (now Part C) was always voluntary, each state has chosen to develop a statewide system and, as of October 1, 1994, has committed to seeing that services are available to every eligible child and his or
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her family. The U.S. Department of Education, through OSEP, distributes funds under Part C to the states to help them carry out collaborative systems planning, policy development, and implementation of needed services for infants and toddlers who have disabilities.
The number of very young children using assistive technology (AT) has increased dramatically over the past 4 years. Besides assistive technology devices and services, states provide a variety of other services to children from birth to 2 years old, such as special education; physical and occupational therapy, nutrition services; audiology‑, nursing services; speech‑language pathology; family training, counseling, and home visits; and vision services. The services to be provided to the child with a disability and the family are documented in an Individualized Family Service Plan (IFSP). Development of the IFSP, as with the IEP, is based on assessments of a child's capabilities, skills, and needs and is constructed through a team approach that includes family members.
Assistive Technology Act of 1998.
Designated as PL 105‑394, the Assistive Technology Act replaced the
Technology‑Related Assistance for Individuals with Disabilities Act of
1988 (PL 100‑407) and the°_ amendments to that law (PL 103‑218)
enacted in 1994. The Tech Act, PL 100‑407, which ended in 1998, was the
first federal legislation that specifically addressed expansion of the
availability of assistive technology devices and services to individuals with
disabilities. The replacement, the AT' Act, carries over many
of the concepts of the Tech Act. It extends funding to the 50 states,
the
1. Support states in sustaining and strengthening their capacity to address the assistive technology needs of individuals with disabilities
2. Support the investment in technology across federal agencies and departments that could benefit individuals with disabilities
3. Support microloan programs to individuals wishing to purchase assistive technology devices or services
The AT Act is divided into three parts: Title 1, State Grant Programs; Title II, National Activities; and Title III, Alternative Financing Mechanisms.
Title I provides grants to states to support capacity building and advocacy activities designed to assist the states in maintaining permanent, comprehensive, consumerresponsive, statewide programs of technology‑related assistance. These include public awareness, interagency coordination, technical assistance and training to promote access to assistive technology, and support to community‑based
organizations that provide assistive technology devices and services or assist individuals in using assistive technology. Title I also provides legal protection and advocacy services; funding for technical assistance, including a national public Internet site; and technical assistance to the states.
Title II provides for increased coordination of federal efforts related to assistive technology and universal design. It authorized funding for multiple grant programs from fiscal years 1999 through 2000, including grants for universal design research, Small Business Innovative Research grants related to assistive technology, grants to commercial or other organizations for research and development related to universal design concepts, grants or other mechanisms to address the unique assistive technology needs of urban and rural areas and of children and the elderly, and grants or other mechanisms to improve training of rehabilitation engineers and technicians.
Title III requires the secretary of education to award grants to states and outlying areas to pay for the federal share of the cost of the establishment and administration of, or the expansion and administration of, specified types of alternative financing systems for assistive technology for people with disabilities. These alternative‑fimding mechanisms may include a low‑interest loan fund, an interest buy‑down program, a revolving loan fund, a loan guarantee or insurance program, and others (RESNA Technical Assistance Project, 1999).
The Developmental Disabilities Assistance and Bill of Rights Act. The Developmental Disabilities program was originally enacted as Title I of the Mental Retardation Facilities and Construction Act of 1963 (PL 88‑164) and has been amended eight times since then. This program provides grants to states for developmental disabilities councils (DD Councils), university‑affiliated programs (UAPs), and protection and advocacy activities for persons with developmental disabilities (PADD). Grants to UAPs include grants for training projects with respect to assistive technology services for the purpose of assisting universityaffiliated programs in providing training to personnel who provide, or will provide, assistive technology services and devices to individuals with developmental disabilities and their families. Such projects may provide training and technical assistance to improve access to assistive technology services for individuals with developmental disabilities and may include stipends and tuition assistance for training project participants.
Americans with Disabilities Act (
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To be protected by the
The
The standards for determining employment discrimination
under the Rehabilitation Act are the same as those used in Title I of the
Americans with Disabilities Act. Title I requires employers with 15 or more
employees to provide qualified individuals with disabilities an equal
opportunity to benefit from the full range of employment‑related
opportunities available to others. For example, it prohibits discrimination in
recruitment, hiring, promotions, training, pay, social activities, and other
privileges of employment. It restricts questions that can be asked about an
applicant's disability before a job offer is made. Many issues of employment
involve the use and application of assistive technology, because Title I of the
Title II covers all activities of state and local governments regardless of the government entity's size or receipt of federal funding. Title II requires that state and local governments give people with disabilities an equal opportunity to benefit from all their programs, services, and activities (e.g., public education, employment, transportation, recreation, health care, social services, courts, voting, and town meetings).
State and local governments are required to follow specific architectural standards in the new construction and alteration of their buildings. They also must relocate programs or otherwise provide access in inaccessible older buildings. In addition, the use of assistive technology such as specialized computer software impacts the requirement that Title II entities must communicate effectively with people who have hearing, vision, or speech disabilities; this includes screen readers, enlarged computer screens, and augmentative and alternative communication devices. Public entities are not required to take actions that would result in undue financial and administrative burdens. They are required to make reasonable modifications to policies, practices, and procedures where necessary to avoid discrimination, unless they can demonstrate that doing so would fundamentally alter the nature of the service, program, or activity being provided.
The transportation provisions of Title II cover public transportation services, such as city buses and public rail transit (e.g., subways, commuter rails, Amtrak). Public transportation authorities may not discriminate against people with disabilities in the provision of their services. They must comply with requirements for accessibility in newly purchased vehicles, make good faith efforts to purchase or lease accessible used buses, remanufacture buses in an accessible manner, and, unless it would result in an undue burden, provide paratransit where they operate fixed‑route bus or rail systems. Paratransit is a service in which individuals who are unable to independently use the regular transit system (because of a physical or mental impairment) are picked up and dropped off at their destinations.
Title III covers businesses and nonprofit service providers that are public accommodations, privately operated entities offering certain types of courses and examinations, privately operated transportation, and commercial facilities. Public accommodations are private entities that own, lease, lease to, or operate facilities such as restaurants, retail stores, hotels, and movie theaters; private schools; convention centers; doctors' offices; homeless shelters; transportation depots; zoos; funeral homes; day care centers; and recreation facilities, including sports stadiums and fitness clubs. Transportation services provided by private entities are also covered by Title III.
Public accommodations must comply with basic nondiscrimination requirements that prohibit exclusion, segregation, and unequal treatment. They also must comply with specific requirements related to architectural standards for new and altered buildings and reasonable modifications to policies, practices, and procedures. In addition, public accommodations must utilize assistive technology for their requirement to offer effective communication for people with hearing, vision, or speech disabilities, as well as other access requirements. Additionally, public accommodations must remove barriers in existing buildings where it is easy to do so without much difficulty or expense, given the public accommodation's resources.
Courses and examinations related to professional, educational, or trade‑related applications, licensing, certifications, or credentialing must be provided in a place and manner accessible to people with disabilities, or alternative accessible arrangements must be offered. For example, courses and examinations given via a computer should utilize appropriate computer assistive technology for people with vision, hearing, or cognitive disabilities.
Title IV addresses telephone and television access for people with hearing and speech disabilities; this has wide assistive technology implications, especially as emerging and developing technologies in the telecommunications and television fields are changing at a rapid pace. Title IV requires common carriers (telephone companies) to estab
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fish interstate and intrastate telecommunications relay services (TRS) 24 hours a day, 7 days a week. TRS enables callers with hearing and speech disabilities who use text telephones (TTYs) and callers who use voice telephones to communicate with each other through a third‑party communications assistant. The Federal Communications Commission (FCC) has set minimum standards for TRS services. Title IV also requires dosed captioning of federally funded public service announcements.
Widely hailed as a major civil rights bill for the disabled,
the
Medicaid. Medicaid is a federal and state program authorized under Title XIX of the Social Security Act of 1965 (42 U.S.C. §§1396. et. seq.). It is an income, or "means‑tested," program, so eligibility depends on a person's income level. Although the program was established by federal legislation, eligibility and services differ from state to state. The federal government (through the Health Care Financing Administration [HCFAJ) sets general program requirements and provides financial assistance to the states by matching state expenditures. This match is based on the relative wealth of each state, ranging from an 80% federal match to the poorest state down to 50% for the wealthiest.
The states are responsible for administering the program consistent with a State Plan submitted to HCFA. Although states do not have to participate in the plan, all 50 states do so. The State Plan specifies who is eligible for services and what services are covered. The Medicaid program neither provides services directly nor pays cash assistance directly to individuals who need medical care. Rather the program reimburses providers (e.g., doctors, pharmacies, hospitals, therapists) for covered supplies and services rendered to qualified recipients.
An individual who seeks Medicaid funding for AT must generally meet a three‑part test: (1) The individual must be eligible for Medicaid; (2) the specific device requested must be one that can be funded by the Medicaid program; (3) the individual must establish that the device requested is medically necessary.
As Medicaid‑funded AT is considered., it is important to distinguish benefits available to adults age 21 or older from those available to children up to age 21 under the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program (42 U.S.C. §1396[a][4][BJ; 42 C.F.R. §§441.50441.62).
In order to qualify for AT as an adult, the device in question must be available under the state's Medicaid plan or it must be available under a specific Medicaid waiver program (such as the home or community‑based waiver).
These waivers allow states to provide services that are not otherwise furnished under the Medicaid plan to a specific population within the state. However, under the law, certain Medicaid services are mandatory; that is, they must be made available to Medicaid beneficiaries, whereas others are optional. As shown in Box 1‑3, there are 11 separate Medicaid service categories that have been identified for funding assistive technology or durable medical equipment
Each service category is specifically defined in the federal regulations. For example, 42 C.F.R. §§440.70(b)(3) defines medical supplies, equipment, and appliances as mandatory items under home health services; 440.110 defines physical therapy, occupational therapy, and speech, hearing, and language therapy, 440.120(c), prosthetic devices; 440.130(c), preventive services; and 440.130(d), rehabilitation services.
Persons with disabilities who are seeking to use Medicaid as a source of funding for assistive technology must navigate a cumbersome process that usually requires both their specific conditions and needs to be expressed in language designed to fit program criteria. The Medicaid law and its implementing regulations do not provide for the funding of any particular AT devices, nor do they spell out a specific test of medical necessity or other criteria governing when a person is eligible for a specific device. The federal law provides a general framework, and the individual federal regulations often spell out in detail what a particular category contemplates. For example, the federal law indicates that the primary goal of Medicaid is to provide medical assistance to persons in need and to furnish them with rehabilitation and other services to help them "attain or retain capability for independence or self‑care" (42 U.S.C. §1396). The federal regulations provide that "each service must be sufficient in amount, duration and scope to
Box 1‑3 Categories of Medicaid Funding for Assistive Technologies
MANDATORY SERVICE CATEGORIES FOR AT FUNDING
• Home health care services (medical supplies, equipment, and appliances)
• Early Periodic Screening, Diagnosis and Treatment (for children)
OPTIONAL SERVICE CATEGORIES FOR AT FUNDING
• Home health care (home health aide and personal care services)
• Intermediate care facilities
• Occupational therapy
• Physical therapy
• Preventive services
• Private duty nursing
• Prosthetic devices
• Rehabilitation services
• Speech, hearing, and language therapy
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reasonably achieve its purpose" (42 C.F.R. §440.230[b]). The law of each state may also provide language that can be referenced for interpretive guidance.
Early Periodic Screening, Diagnosis and Treatment Program. EPSDT is a mandatory service under Medicaid (42 U.S.C. §§1396a[a][l0A]; 1396d[a][4][B]; 1396d[r]). EPSDT services are available for children from birth through age 21. A state must provide Medicaid beneficiaries under age 21 any service among those listed in the Medicaid Act, including optional services, whether or not the service is included in the state's Medicaid plan. Screenings include a physical examination; assessment of developmental, nutritional, and mental health; and vision, hearing, and dental examinations. According to federal law, if a condition is identified at an EPSDT screening, Medicaid must then cover all follow‑up care that is medically necessary regardless of any limits a state might impose on ;such services. The EPSDT program offers a significant opportunity for funding of assistive technology that is not otherwise provided by Medicaid.
Medicare. The Medicare Program was authorized under Title XVIII of the Social Security Act of 1965. Medicare is administered by the federal government, and the rules are the same for every state in the nation. Medicare is another major funding source for assistive technology, which in the language of both the Medicare and Medicaid systems is called durable medical equipment (DME).
Medicare is a health insurance program for (1) individuals age 65 or older, (2) people of all ages who are permanently and totally disabled, and (3) people with end‑stage renal disease. It is divided into two parts. Part A, known as "hospital insurance," covers inpatient services, posthospital care in skilled nursing homes, hospice care:, and home health care. Home health care includes durable medical equipment, occupational and physical therapy, and speechlanguage pathology (SLP) services. Part B, known as "supplemental medical insurance," covers physician's services; laboratory services; durable medical equipment; medical supplies; prosthetic devices; rehabilitation therapy services, including SLP services; and home health care for beneficiaries not covered by Part A.
The Medicare program is a cost‑sharing one in which both beneficiary and federal contributions are used. Beneficiary contributions include cash deductions and coinsurance requirements under Parts A and B and monthly premiums for Part B. State Medicaid programs can assume the Medicare cost‑sharing requirements for those individuals who qualify for both Medicare and Medicaid.
Assistive technology items are categorized by Medicare
as durable medical equipment. Medicare defines DME as equipment that (1) can withstand repeated use, (2) is primarily and customarily used to serve a medical pur
pose, (3) generally is not useful to a person in the absence of illness or injury, and (4) is appropriate for use in the home.
Certain items that do not meet the criteria listed above may be covered under a special exception when the items clearly serve a therapeutic purpose. To establish the medical necessity for the item, it must be included in the physician's treatment plan and a physician must supervise its use.
Payment for DME items is subject to the requirement that the equipment be necessary and reasonable for the treatment of an illness or injury or will improve the functioning of a malformed body member. Although an item may be medically necessary, it may not be covered by Medicare if (1) the cost of the item is disproportionate to the therapeutic benefits derived from its use, (2) the item is more expensive than an appropriate alternative, or (3) the item serves the same purpose as equipment already available to the beneficiary.
Medicare excludes many items for coverage. Although there are many specific bases for such exclusions, they generally are based on the principle that Medicare is a program, like insurance, to provide "medical care." Therefore items are excluded if used for "personal comfort" or "custodial care."
Now that we have defined assistive technology and reviewed historical and legislative factors affecting the delivery of assistive technology, we can describe the structure of the assistive technology industry. Figure 1‑2 depicts the components of the assistive technology industry and how they are interrelated. It is important to be aware of the function of each component, its contribution to the industry, and the necessary interaction among these components.
Without a consumer who uses the assistive technology devices and services, all the components in Figure 1‑2 are unnecessary. Likewise, without a delivery system that actually provides the technology to the consumer, the supporting components in Figure 1‑2 are ineffective. For this reason, we have shown the consumer and direct consumer services at the center of the figure. However, it is important to note that the consumer may be involved in all aspects of the industry.
Direct consumer services is the component in which a consumer's need for assistive technology is identified, an evaluation is completed, recommendations are made, and the system is implemented. The steps in providing these services are described in Chapter 4.
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Figure 1‑2 The assistive technology industry. The components center around the delivery of devices and services to consumes through direct services. The other industry components are arranged to illustrate their relationships to each other. (Modified from Smith RO: Models of service
delivery in rehabilitation
technology. In Perlman LG and Enders A: Rebabilitation service delivery: a practical guide,
The consumer. The consumer of assistive technologies is viewed primarily as the recipient, or end user, of assistive technology. With this in mind, the industry components should be responsive to the consumer, his or her needs, and recommendations based on utilization of assistive technology services and products. As assistive technology systems are applied in the "real world," information from the consumer (and direct service providers) flows out to the other components so that changes in products and services can be made. Likewise, the other components interact among themselves and ultimately affect the consumer and the direct consumer service providers through research, new product development, and dissemination of information.
The consumer should not, however, be viewed solely as the recipient of the technology. The consumer must be considered an active participant in the other industry components as well if the application of assistive technologies is to be effective and the industry is to grow. A number of sources recognize the many roles of the consumer in the
assistive technology industry. Corthell (1986) used the term consumer as co‑developer
to describe a philosophy wherein the consumer is involved in all aspects of the
assistive technology industry. The National Institute on Disability and
Rehabilitation Research (NIDRR) furthers this concept by stressing the
importance of participatory research in assistive technology. As
Consumers can also be effective in training others in how to use a particular device and in assistive technology education. For example, the Empowering End Users through Assistive Technology (EUSTAT) project in Eu
Page 18
rope has developed guidelines for trainers, a set of critical factors for assistive technology training and descriptive information on programs that provide assistive technology training for consumers (www.siva.it/research/eustat). One of the documents developed by EUSTAT is written for consumers of AT services and gives practical guidance regarding how to access these services. Keep in mind, as you read about each component of the assistive technology industry, that there are many ways in which consumers can be and are involved.
Characteristics of direct consumer service programs. Assistive technology systems and services are delivered to the consumer through a variety of models and in different types of settings. There are several attributes that set direct consumer service programs apart from one another. The primary distinguishing factor, and the one most commonly used, is the type of administrative setting in which the service delivery program exists (Smith, 1987). Based on Smith's classification, Box 1‑4 describes models of service delivery programs according to their administrative setting.
Smith (1987) also identifies several distinguishing features of service delivery programs. The purpose and mission may differ among service delivery programs. The purpose of some programs may be only to provide one‑time evaluations, whereas other programs may provide comprehensive assistive technology services. The functional areas, or types of services, provided by assistive technology service delivery programs is another variable. Augmentative communication, seating and mobility, orthotics and prosthetics, sensory aids, computer access, robotics, and driving are some of the functional areas in which services are rendered. One program is unlikely to provide services in all these areas. Programs usually focus on a few of these functional areas.
The type of population served by are assistive technology program may be another distinguishing feature. For example, the United Cerebral Palsy Association (UCPA) supports a number of programs involving assistive technology that serve adults with cerebral palsy. The requirement for a military service‑connected disability distinguishes the population served by the Veterans' Administration. Service delivery programs also differ depending on the geographical area that they serve. Some programs are community based in that
they are set up strictly to serve individuals in their community. Other programs provide specialised evaluation services to a large geographical region. On a larger scale, there are also providers such as national equipment distributors that have offices throughout the nation. Whether the program is in a rural or an urban area is another geographical factor reflected in the types of services provided. For example, programs in rural service delivery areas need to be able to provide services to farmers who have work‑related injuries and require adaptation of their farm machinery in order to continue their livelihood.
In order to serve consumers who do not live in urban areas, some assistive technology service delivery occurs through telerehabilitation programs. Telerebabilitation refers to the use of telecommunications technologies to capture and transmit visual and audio information, biomedical data (e.g., electroencephalograms (EEGs, x‑ray films, ultrasound data), and consumer information (Kim, 1999). In assistive technology service delivery, telerehabilitation (telerehab) is used for preassessment screening, postassessment training in device use, and the provision of follow‑up services. Transmission of telerehab data may be via computer interfaces over the Internet, via telephone lines, or via satellite. For home use there are small units that resemble fax machines (Kim, 1999). These portable units allow follow‑up in a consumer's home. Scheck (1998) describes several examples of the use of telerehab for assistive technology service delivery, one of which is the use of telerehab for training in augmentative and alternative communication (AAC; see Chapter 9). In this application the speech‑language pathologist uses a small "document camera" (typically used for projecting images onto a screen or photographing them for transmission) to visualize the symbol display on the AAC device. Another camera focuses on the consumer, and a microphone picks up the synthesized speech produced by his AAC device. The speech‑language pathologist can provide both instruction and evaluation from her office while the consumer remains in his home.
Burns et al (1998) describe four case studies that illustrate the application of telerehabilitation to support the use of assistive technologies in the home. The four cases are (1) seating evaluation (see Chapter 6), (2) setup of a computer access system (see Chapter 8), (3) home accessibility evaluation (see Chapter 4), and (4) training in the use of an augmentative communication system (see Chapter 9). As Burns et al point out, telerehabilitation can overcome some of the difficulties faced by individuals who live at a distance from centers that provide assistive technology services. Low‑cost video telephone technology was utilized in these studies. This technology, which has some limitations for studies involving full motion, was chosen because it depends only on standard telephone lines for implementation. For cases in which a family did not have a phone, cellular telephone transmission was used. Each of the cases described by Burns et al was initiated by the delivery of the telerehabilitation technology to the patient's home (often by mail). The family was then instructed in the use of the equipment (by telephone from the rehabilitation center), and the consultation was conducted remotely. The results that they obtained, although preliminary, are encouraging,
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Direct Consumer Service Delivery Settings
REHABILITATION SETTING
Assistive technology services are part of a comprehensive rehabilitation program; may be a part of one of the therapy departments or its own department. The primary purpose is to support the other :services of the rehabilitation setting; therefore there is usually multidisciplinary team involvement. Typical populations served are persons with spinal cord injuries, head injuries, cerebral vascular accidents, and amputations. Services are usually billed to third‑party health insurance payers.
UNIVERSITY BASED
Programs in this setting have largely evolved from a research component and may provide direct consumer services, as well as education and training. Staff usually consists of personnel capable of performing clinical, research, and educational duties. The types of professionals involved in the team depend on the functional areas addressed by the setting. Those settings conducting research provide a national service. The direct consumer service component is usually regionally oriented. Funding is largely grant and contract related (particularly for the research component), although portions of the direct consumer services may be billed to third‑party payers.
STATE AGENCY PROGRAM BASED
State agency‑based programs are usually a part of vocational rehabilitation departments or special education departments. Those programs based in vocational rehabilitation departments are statewide programs developed for the purpose of providing assistive technology services to individuals who need it for attaining or sustaining employment. The purpose of programs within special education departments is to facilitate the education of school‑aged children. In some instances, school districts have their own multidisciplinary team. In other cases there may be a team that covers the entire state. Administration of these programs varies and may be statewide or on a local level. Funding is usually mandated at the state or federal level and designated for these agencies.
PRIVATE PRACTICE
A small number of assistive technology providers have gone into private practice. They may provide consultation to state agencies or rehabilitation centers. The population and functional service area varies and depends upon the professional backgrounds of those involved in the business. Operated as a for‑profit, small‑business venture with fees for service charged. Usually based in one local area.
DURABLE MEDICAL EQUIPMENT SUPPLIER
Usually these suppliers are for‑profit agencies that addresses a range of equipment needs. Typically they provide walking aids, bathing and toileting aids, wheelchairs, and seating systems. Some suppliers may provide communication and environmental control equipment. DME suppliers are reimbursed by third‑party payers. DME suppliers are known for their technical resources and ability to provide repair and maintenance services. There are some DME suppliers that operate on a nationwide basis; others are loco( operations.
VETERANS' ADMINISTRATION (VA)
Assistive technology services are provided at many of the Veterans' Administration hospitals. There is usually a multidisciplinary team approach. Research in the field of assistive technology is a large component of the services provided by the VA, and significant contributions have been made in this area. The population served is restricted to veterans with servicerelated disabilities. Veterans with spinal cord injury have been a major group served by the VA.
LOCAL AFFILIATE OF A NATIONAL NONPROFIT DISABILITY ORGANIZATION National organizations such as the United Cerebral Palsy Association (UCPA), Easter Seal Society, Muscular Dystrophy Association (MDA), Association for Retarded Citizens (ARC), and American Foundation for the Blind provide assistive technology services through their local affiliates. The purpose of these organizations is often to serve individuals with a particular disability; therefore the populations served and the functional areas are geared primarily toward that disability group. Programs of the focal chapters are usually administered at the local level, and assistive technology services vary among affiliates. Some local chapters may have a complete assistive technology team to provide services, whereas other chapters may only loan equipment. Funding for these agencies is through grants, contracts, donations, and fundraising events.
VOLUNTEER PROGRAMS
Volunteer organizations in the United States that provide assistive technology services include groups such as the Telephone Pioneers of America, the Volunteers for Medical Engineering, and Rehabilitation Volunteer Network. Most of these groups have developed out of private industry and have as their purpose the provision of a philanthropic service. These groups usually provide services on a local or regional basis. The functional areas served depends on the expertise of the volunteers involved.
Page 20
and they provide useful information regarding the pros and cons of distance consultation through the use of telerehabilitation technology.
The internal operations of a service delivery program are another characterization. These include the structure of the organization (from large corporation to small, privately owned company), the number and type; of professionals employed to provide the services, and whether the consumer must come in to the center for services or a van or mobile unit goes out to see them.
The final descriptor of service delivery programs is how the services are funded. Some assistive technology service delivery programs are funded under the general overhead of a larger organization, such as programs based within a rehabilitation hospital. Some programs are supported by grant funding, whereas others rely on a fee for service charged to third‑party payers. Sources of third‑party funding and mechanisms for obtaining fundiing for individual consumer services and equipment are discussed in detail in Chapter 5.
The major goal of basic research is the generation of new knowledge. Research hypotheses are posed that address fundamental questions regarding physical or biological phenomena. There are basic research questions that underlie the successful application of assistive technologies. For example, basic neuroscience studies that help to describe movement patterns in persons with disabilities provide the fundamental basis on which new control interfaces can be designed (see Chapter 7).
The single most distinguishing feature of basic research in assistive technologies is that the outcomes are not known beforehand, although hypotheses are proposed. By carrying out basic investigations, we can begin to better understand how the presence of a disability affects functional performance and how this may be taken into account when designing an assistive device. Throughout this text we describe basic research studies that underlie the successful development and application of assistive technologies.
The distinction between basic and applied research is not precise, and there is some overlap. However, in the area of assistive technology application the distinction between these two types of research is dearer than in the general case. There are many types of applied research studies in assistive technology. We can group them as follows: (1) testing of assistive devices under various operating conditions to answer a performance question; (2) development of new assistive devices based on clinical need, basic research find
ings, or both; (3) research on the use of assistive technologies by persons with disabilities; and (4) research studies designed to develop new assessment or training approaches or materials.
An example of the testing of devices is the use of performance standards to test wheelchairs or other devices (Axelson and Phillips, 1989). In some cases, such as wheelchairs, there are accepted standards against which devices are tested (see Chapter 10). In other cases, such as augmentative communication systems (Chapter 9), there is no generally accepted standard, but a device or series of devices can be evaluated against operational characteristics developed specifically for the research study (Dahlquist et al, 1981). Another example of an applied or clinical research study related to assistive technology use is the study of the effects of adaptive seating o