Research in Developmental Disabilities 32 (2011) 576–582
Contents lists available at ScienceDirect
Research in Developmental Disabilities
Microswitch and keyboard-emulator technology to facilitate the writing
performance of persons with extensive motor disabilities
Giulio E. Lancioni a,*, Nirbhay N. Singh b, Mark F. O’Reilly c, Jeff Sigafoos d, Vanessa Green d,
Doretta Oliva e, Russell Lang f
a
Department of Psychology, University of Bari, Via Quintino Sella 268, 70100 Bari, Italy
ONE Research Institute, Midlothian, VA, USA
Meadows Center for Preventing Educational Risk, University of Texas at Austin, TX, USA
d
Victoria University of Wellington, New Zealand
e
Lega F. D’Oro Research Center, Osimo (AN), Italy
f
Texas State University, San Marcos, TX, USA
b
c
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 2 December 2010
Accepted 14 December 2010
Available online 12 January 2011
This study assessed the effectiveness of microswitches for simple responses (i.e., partial
hand closure, vocalization, and hand stroking) and a keyboard emulator to facilitate the
writing performance of three participants with extensive motor disabilities. The study was
carried out according to an ABAB design. During the A phases, the participants (one child
and two adults) were to write using the responses and technology available to them prior
to this study. During the B phases, they used the new responses and technology. Data
showed that two of the three participants had a faster writing performance during the B
phases while the third participant had a slower writing performance. All three participants
indicated a clear preference for the use of the new responses and technology, which were
considered relatively easy and comfortable to manage and did not seem to cause any
specific signs of tiredness. Implications of the findings are discussed.
ß 2010 Elsevier Ltd. All rights reserved.
Keywords:
Microswitches
Vocalization
Hand closure
Hand stroking
Scanning keyboard emulator
Writing
Motor disabilities
1. Introduction
Literacy skills (i.e., reading and writing) are highly valued targets of all educational programs and represent a clear
objective for any person irrespective of age (Dudgeon, Massagli, & Ross, 1996; Light, McNaughton, Weyer, & Karg, 2008;
Simpson, Gauthier, & Prochazka, 2010). These skills can help the person enhance the learning process and cognitive
development, promote information and communication, foster personal interactions and social respect, and allow access to a
variety of computer-mediated communication (e.g., electronic mail) and leisure (e.g., videogame) opportunities (Bache &
Derwent, 2008; Huo, Wang, & Ghovanloo, 2008; Lathouwers, de Moor, & Didden, 2009; Light et al., 2008).
The importance of those skills and, particularly, of writing may be even greater for persons with extensive motor
disabilities because they often have huge difficulties communicating and occupying themselves in a constructive and
enjoyable manner (Light et al., 2008; Simpson et al., 2010). The increased importance of writing for these persons contrasts
with the serious problems they encounter in performing such an activity. To alleviate these problems two main strategies
can be considered. One concerns the use of specially adapted keyboards (Man & Wong, 2007; Peeters, Verhoeven, van
Balkom, & de Moor, 2009; Turpin et al., 2005). The other concerns the use of special sensors that can be interfaced with a
* Corresponding author.
E-mail address: [email protected] (G.E. Lancioni).
0891-4222/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ridd.2010.12.017
G.E. Lancioni et al. / Research in Developmental Disabilities 32 (2011) 576–582
577
computer system and a virtual keyboard or similar letter displays (Pereira, Neto, Reynaldo, de Miranda Luzo, & Oliveira,
2009; Varona, Manrea-Yee, & Perales, 2008; Weightman et al., 2010).
The adapted keyboards may have different shapes and sizes or may include keyguard covers (i.e., to facilitate the motor
responses required for the writing activity and guide such responses to target one letter at a time). In spite of their facilitative
features, the overall effectiveness of these keyboards may be negligible and/or their use may be very tiring for participants
who present with particularly serious motor disabilities (Davies, Mudge, Ameratunga, & Stott, 2010; Lontis & Struijk, 2010;
Man & Wong, 2007; Turpin et al., 2005).
Special sensors monitoring responses, such as head movements or eye and eyelid movements, and translating them into
computer inputs and eventually writing actions have been developed and put forward during the last decade (Betke, Gips, &
Fleming, 2002; Borghetti, Bruni, Fabbrini, Murri, & Sartucci, 2007; Chen, 2001; Evans, Drew, & Blenkhorn, 2000; Turpin et al.,
2005). For example, Chen (2001) developed a head-operated computer mouse that relied on (a) two tilt sensors fixed to a
headset to keep track of the user’s head position and (b) a touch microswitch that monitored the user’s face (cheek). In
practice, the tilt sensors determined any user’s head motion (e.g., up, down, left, and right) and oriented and moved the
cursor accordingly. The touch microswitch responded to cheek puffs translating them into mouse clicks. Borghetti et al.
(2007) used eye movements and blinks as tools to control the movements of a cursor over an alphanumeric matrix and to
select and write the letters, respectively.
Recently, efforts have been made to assess new sensors (microswitches). Those microswitches (a) were considered
minimally/moderately invasive (i.e., compared to the aforementioned ones) and (b) monitored single, relatively simple
responses (e.g., deemed less demanding/tiring than combinations of head movements and cheek puffs or of eye rotations and
eyelid closures) to be performed in relation to scanning keyboard emulators (Lancioni et al., 2007, 2009, 2010). For example,
Lancioni et al. (2009) conducted a study with two children using basic voice-detecting microswitches to monitor their vocal
responses and translate them into inputs for a scanning keyboard emulator. Those microswitches allowed the participants to
select the letters needed as they were automatically scanned on the keyboard emulator (and thus write words) through
simple vocal emissions. The results showed that the new microswitch solution (a) was as effective as or more effective than
the previous ones available to the participants (i.e., head- or hand-activated microswitches) in terms of writing speed, (b)
was less demanding than the previous ones in terms of effort required, and (c) was preferred by both children.
The encouraging results obtained with this last approach (i.e., use of microswitches for single, simple responses and
scanning keyboard emulators) are based on only six participants and thus need to be supported by the data of additional
participants to gain credibility (Kennedy, 2005). New research initiatives to determine the consistency of these early results
may also explore the possibility of including participants who present some differences compared to those involved in
previous studies to extend the scope of the assessment (Kazdin, 2001; Kennedy, 2005). This study was an effort in that
direction. It involved a child and two adults in their forties (i.e., an age range not included before). All three participants had
been provided with writing programs, but these seemed quite difficult and tiring.
2. Method
2.1. Participants
The participants (Stephanie, Dermot, and David) were 13, 45 and 46 years old, respectively. Stephanie was considered to
be between a typical intellectual-ability range and a borderline condition (but no IQ scores were available for her given the
difficulties in using formal testing). She presented with a severe condition of cerebral palsy with spastic tetraparesis and very
serious problems of hypertonia with multiple dystonic movements. She was in a wheelchair and had no specific, functional
responses that would enable her to develop self-help skills. She could speak with extreme difficulty (using brief utterances
which were often understood only by familiar listeners), and could understand spoken language as well as written text. She
was living at home with her parents and attended an integrated education curriculum within an inclusive setting and had
been provided with a technology-based program for writing. Such a program included a computer-supported keyboard that
could be used through a modified joystick sensor. This could be moved to find the letters and could be clicked to select/write
those letters. These combinations of movements could be quite demanding and tiring for Stephanie.
Dermot’s childhood psychological records spoke of a borderline intellectual functioning level. Subsequent reports
suggested an apparently typical level of intellectual functioning with minimal motor abilities and adaptive behavior due to
spastic tetraparesis with dystonic movements. He was in a wheelchair, spoke with a certain level of difficulty and his
utterances were not always clear to the listener. He could follow conversations on various aspects of everyday life and
enjoyed intervening to provide his view. He also had an interest in writing, but had never been able to find a practical
strategy for it. Indeed, a recent strategy involving the use of a pressure microswitch for a foot response to perform in relation
to a scanning keyboard emulator was considered very tiring. An earlier strategy involving the use of a voice-detecting
microswitch relying on an airborne microphone for vocal emissions was considered unreliable. He was living at his parents’
home and attended a day center that ensured physiotherapy and leisure activities (e.g., small outdoor trips and films).
David was considered to have a typical level of intellectual functioning, was diagnosed with spastic tetraparesis and
epilepsy (partially controlled through medication) and was confined to a wheelchair. His communication and interaction
skills were similar to those mentioned for Dermot. His motor condition was slightly better than that of Dermot. In fact, he
could move his right arm and hand albeit with some fatigue. Given this motor condition, he had been involved in a writing
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G.E. Lancioni et al. / Research in Developmental Disabilities 32 (2011) 576–582
program, which relied on the use of a keyboard with keyguard cover. This program was however viewed as very tiring and
David only used it for brief periods of time. He was living at his father’s home, and attended the same day center and received
the same physiotherapy and leisure activities as Dermot.
All participants had expressed their interest in the new writing program and agreed to use the microswitches and
responses selected for them (see below). The participants’ families had provided informed consent for the implementation of
the study, which had also obtained the formal approval of a scientific and ethics committee.
2.2. Responses, microswitches, and keyboard emulator
The responses selected for the three participants consisted of a small/partial hand closure, vocalization (i.e., brief sound
emission), and a slight hand movement (i.e., hand stroking), respectively. The microswitch for Stephanie consisted of a
touch/pressure device attached to the palm of her right hand that would be activated as soon as she performed small (partial)
hand-closure responses. The microswitch for Dermot consisted of a voice-detecting device (i.e., a small electronic unit at
Dermot’s chest) with an airborne microphone and a throat microphone. This combination of microphones prevented false
microswitch activations due to environmental noise or dystonic movements (Lancioni et al., 2009). The microswitch for
David consisted of a touch pad fixed on his right leg, which was activated by a simple stroking of his right hand that he
normally kept/rested on that leg.
The responses were considered most suitable for the participants (i.e., relatively fast, reliable, and comfortable over time).
The microswitches were selected based on the notion that they (a) could reliably match the responses and (b) appeared the
simplest solutions (i.e., with regard to practicality, invasiveness/conspicuousness and cost) available for those responses
(Lancioni et al., 2010). The microswitches worked as basic interfaces that translated small (non-specific) responses into
appropriate input for the scanning keyboard emulator.
The keyboard emulator was a commercially available product (i.e., QualiKey by QualiLife UK, Kent TN15 7DA), which
worked though a portable personal computer and was adjusted to the participants’ conditions, as to the number of keys used
and the key scanning speed. Specifically, only the letter keys were scanned. Those keys were arranged in six rows. Following
the participant’s initial response (i.e., microswitch activation), the first row of letters was illuminated for a preset time, which
varied across participants and program/intervention stages (e.g., 2 s; see below). The participant was to provide a
microswitch response within that time if the letter he or she needed to write was in that row. Otherwise, he or she had to
wait until the row containing that letter was illuminated. Following the microswitch response on the row, the letters on it
were scanned/illuminated individually. The selection of the letter (i.e., with a microswitch response while the letter was
scanned) wrote that letter on the computer screen. This was followed by a re-illumination of the row and a continuation of
the process as described above.
The responses and the technology available prior to this study (and used as baseline conditions) were described in Section
2.1. They consisted of (a) hand movement to activate a joystick and select letters on a virtual keyboard for Stephanie, (b) foot
movement with a pressure microswitch and a scanning keyboard emulator for Dermot, and (c) key pressing on a keyboard
equipped with a keyguard cover for David.
2.3. Writing sessions and data collection
Writing sessions typically included five or six words of four to eight letters. Sessions could be followed by brief
conversations with the research assistant on preferred topics such as sport and travels for Dermot and David and the
watching of brief video-cartoons for Stephanie (i.e., by forms of activity which were considered pleasing for the participants
and possibly motivating for their efforts). Data collection consisted of recording (a) the time required for writing the words
provided during the sessions and (b) the participants’ answers to the preference checks, that is, whether they preferred to use
the new response and microswitch with the scanning keyboard emulator or the response and technology available prior to
this study (and used during the baseline phases of this study; see below). Interrater agreement was assessed in about 30% of
the sessions regarding the time for writing the words and on all preference checks. Agreement was found on about 95% of the
words (allowing a 6-s discrepancy between observers) on writing time, and on all answers to the preference checks.
2.4. Experimental conditions
The study involved an ABAB sequence in which A represented the baseline phases and B the intervention phases with the
new responses and microswitches and the scanning keyboard emulator (Barlow, Nock, & Hersen, 2009). The first
intervention phase included a gradual reduction of the scanning time applied to the keyboard emulator. The end of the
second intervention phase was followed by a series of 10 preference checks regarding the new responses and technology and
the previous responses and technology. Variations in the numbers of sessions used for the participants during baseline and
intervention phases were due to their performance and availability.
2.4.1. Baseline (A) phases
Each of these phases included 4–8 sessions. The participants used the responses and the technology available prior to this
study (see above). The scanning speed of the keyboard emulator used by Dermot remained at 1.8 s (i.e., based on
G.E. Lancioni et al. / Research in Developmental Disabilities 32 (2011) 576–582
579
observations of his foot responses’ speed). The words included in the sessions were presented in written form and verbally
(for Stephanie) or only verbally (for Dermot and David).
2.4.2. First intervention (B) phase
The participants used the microswitch and response selected for this study together with the scanning keyboard
emulator for 33, 25, and 27 sessions, respectively. These sessions, which were carried out as those in baseline, were
introduced by six, two and five practice sessions of about 15 min for the three participants, respectively. During the practice
sessions, a research assistant provided any support the participant needed to proceed successfully. Initially, the scanning
speed on the QualiKey was set at 3 s for David, 2 s for Stephanie, and 1.8 s for Dermot. Then, this time was reduced, in steps, to
2 s for David, 1.2 s for Stephanie and 1.1 s for Dermot.
2.4.3. Second intervention (B) phase
Conditions were as at the end of the first intervention phase. The participants had 25–36 sessions.
2.4.4. Preference checks
Each participant received 10 preference checks. At every check, the research assistant asked the participant whether he or
she preferred to write through the microswitch and response used in this study or with the material and response available
before. The participant’s choice was followed by a matching session (i.e., a session involving the condition chosen) (Lancioni
et al., 2010).
3. Results
Figs. 1–3 show the mean times required by Stephanie, Dermot and David, respectively, to write the single letters of the
words presented within the sessions of the baseline and intervention phases. The sessions are grouped into two blocks
during the baseline phases and three blocks during the intervention phases and, in this way, provide a view of the
participants’ performance trends. Each block/bar of the figures represents the mean writing time per session over a group of
sessions. The number of sessions included in each block/bar is indicated by the numeral above the bar. Stephanie’s mean
Mean Time per Letter
[()TD$FIG]
BASELINE
30
4
20
6
4
10
1
3
INTERVENTION
4
17
2.0
0
BASELINE
INTERVENTION
2
3
10
12
12
12
1.61.3
1.2
1.2
1.2
1.2
4
5
8
9
10
6
7
Blocks of Sessions
[ STEPHANIE ]
Fig. 1. Stephanie’s data across the four phases of the study. The bars represent the mean time (i.e., seconds) required for writing single letters over blocks of
sessions, each comprising several words. The number of sessions included in the bars is indicated by the numerals above them. The scanning speed (or range
of speeds) used for the keyboard emulator during those sessions is indicated by the numerals inside the bars.
Mean Time per Letter
[()TD$FIG]
BASELINE
INTERVENTION
BASELINE
INTERVENTION
30
2
20
2
4
12
10
0
1.8
1.8
1.8
1.2
1
2
3
4
2
2
1.8
1.8
9
1.1
5
6
7
Blocks of Sessions
[ DERMOT ]
Fig. 2. Dermot’s data plotted as in Fig. 1.
8
9
9
1.1
1.1
1.1
8
9
10
[()TD$FIG]
G.E. Lancioni et al. / Research in Developmental Disabilities 32 (2011) 576–582
580
Mean Time per Letter
BASELINE
INTERVENTION
BASELINE
30
INTERVENTION
8
12
7
20
2
3
3.0
10
0
1
2
3
2.62.1
4
2.0
5
8
2
6
8
9
2.0
2.0
2.0
8
9
10
3
7
Blocks of Sessions
[ DAVID ]
Fig. 3. David’s data plotted as in Fig. 1.
time per letter (computed by dividing the time needed to complete the words by the number of correct letters) was above
20 s (with a range of 12–41 s) during the first baseline phase of the study with the use of the joystick and virtual keyboard.
Her mean time per letter was about 23 s (with a range of 10–37 s) during the initial section of the first intervention phase
with the new microswitch–response combination and the scanning keyboard emulator (i.e., when the scanning speed was
set at 2 s; see first bar of the phase). Such time gradually declined, as the scanning speed increased, and reached about 14 s
(with a range of 7–26 s) per letter by the last 10 sessions of the phase (see the third bar of the phase). Her time data for the
second baseline were similar to (or exceeded) those recorded during the first baseline. Her mean time per letter during the
second intervention phase was similar to that shown at the end of the first phase.
Dermot’s mean time per letter was about 20 s (with a range of 12–32 s) during the first baseline. The first intervention
phase started with a mean time per letter of about 17 s (range of 9–27 s) (see the first bar of the phase). The time then
declined and settled at about 11 s (with a range of 6–20 s) by the last nine sessions of the phase (see the third bar of the
phase). During the second baseline, the mean time per letter was similar to that recorded through the first baseline. During
the second intervention phase, the mean time was similar to (slightly lower than) the time recorded at the end of the first
intervention phase.
David’s mean time per letter was about 10 s (with a range of 5–19 s) during the first baseline. The first intervention phase
started with a mean time per letter of about 25 s (range of 13–39 s) (see the first bar of the phase). The time then declined and
settled at about 17 s (with a range of 7–33 s) by the last seven sessions of the phase (see the third bar of the phase). During the
second baseline, the mean time per letter was similar to that recorded through the first baseline. During the second
intervention phase, the mean time was about 14 s (i.e., slightly lower than the time recorded at the end of the first
intervention phase).
The Kolmogorov–Smirnov test showed that the differences in times per letter between the baseline phases and the
second intervention phase were statistically significant (p < .05) for all three participants (Siegel & Castellan, 1988). For
Stephanie and Dermot, the intervention times were lower while for David were higher. The preference checks showed that
Stephanie chose 9 of the 10 times the new microswitch and response condition. Dermot and David chose the new condition
all 10 times.
4. Discussion
The new microswitch and response conditions arranged for Stephanie and Dermot produced (a) an improvement of their
writing performance (i.e., with a decrease of the mean writing time per letter) and also (b) an apparently more comfortable
(less tiring) engagement that translated into their general preference for that condition. David showed an increase in his
writing time per letter with the new condition, but, at the same time, he had a clear preference for such a condition. In fact,
the use of the touch/pressure microswitch and small hand-stroking response with the scanning keyboard emulator was
considered easy and comfortable and did not seem to cause any specific signs of tiredness while the use of the keyboard with
keyguard cover appeared physically demanding and tiring (cf. Kencana & Heng, 2008; Man & Wong, 2007).
In light of the findings, several considerations may be formulated. First, the microswitches and related responses adopted
during the intervention phases of the study could be viewed as critical for the encouraging data obtained with the
participants. In fact, the microswitches were suitable for simple responses such as partial hand closures, vocalization, and
hand stroking. These responses were relatively undemanding compared to what the participants were used to before the
study and thus suitable to ensure longer periods of writing performance (as required if writing is to become a relevant means
of communication and leisure engagement; see below).
Second, the baseline phases of Dermot did not include a gradual reduction of the scanning time with the pressure
microswitch and foot response available during those phases. Technically, this absence would make the direct comparison
between the writing time in those phases and the writing time during the intervention phases difficult or unfair. While this is
so, a practical consideration recommended against such a reduction. Specifically, the fact that the foot response was difficult
to organize and generally slow to execute suggested that a reduction of the scanning time would be likely to increase the
G.E. Lancioni et al. / Research in Developmental Disabilities 32 (2011) 576–582
581
participants’ difficulties (i.e., misses and frustration). Those difficulties, in turn, would have created extra pressure with
possible negative consequences in terms of performance, fatigue, and acceptance of the writing activity (Huo et al., 2008;
Lancioni et al., 2010; Scherer, Sax, Vanbiervliet, Cushman, & Scherer, 2005).
Third, the results of the preference checks may be taken as a participants’ statement that the new microswitch-response
combination was more satisfactory/functional and less demanding than what was already available to them. The use of a
keyboard with an automatic scanning function (as in this study) can be necessary and highly effective when the participants
have extensive motor disabilities. In fact, these participants would find it extremely difficult (or impossible) to manage two
responses, one to move the cursor to the letters required for the target words and the other to select and write those letters
(Borghetti et al., 2007; Simpson et al., 2010; Varona et al., 2008).
Fourth, the encouraging results of the study reported here should not lead one to minimize the fact that the writing times
remained relatively high even with Stephanie and Dermot and that strategies need to be found to curb them. Efforts to
improve this situation could initially involve revisions of the technology (Backer & Moon, 2008; Lancioni et al., 2009). For
example, one could envisage a more functional/economical scanning process by reducing the number of keys available and
grouping two or three letters on each of the keys. One could also combine the visual scanning process with auditory cues
from the system that could facilitate the identification of the target letters and eventually the response efficacy. Increasing
the participants’ writing speed would have beneficial effects for the practical (communicative) use of such a skill and for the
participants’ sense of efficiency and social respect (Anson et al., 2006; Lancioni et al., 2009; Sugasawara & Yamamoto, 2009).
Fifth, developing writing abilities through suitable technology is not only important to allow participants with extensive
motor disabilities immediate communication and educational progress. In fact, the use of the writing technology can also be
instrumental to allow them access to electronic mail, Internet and leisure-time games (e.g., videogames), with enormous
implications in terms of social development and recreational opportunities (Kehoe, Neff, & Pitt, 2009; Lathouwers et al.,
2009; MacArthur, 2009; Weber, 2006). To ensure such an access, for example, the microswitches and keyboard emulator
could be combined with commercial software such as QualiSURF (QualiLife UK, Kent TN15 7DA) (Moisey & van de Keere,
2007).
In conclusion, this study has provided additional support for the use of microswitches for simple responses with persons
with extensive motor disabilities. Those microswitches may be fairly inconspicuous and the responses may be fairly easy and
convenient (i.e., not tiring) and thus could be used for relatively long periods of time without adverse effects. A shortcoming
of this approach is that the writing process is still rather slow. Future research could be focused on three technical issues.
First, new simple responses could be assessed to extend the range of options available and thus make the approach suitable
to a larger number of individuals. For example, one could consider small tongue movements and tooth clicks as plausible
responses (Huo & Ghovanloo, 2010; Huo et al., 2008; Lancioni et al., 2008; Simpson et al., 2010). Second, the scanning process
could be made more functional/economical by reducing the number of keys available and grouping two or three letters on
each of the keys. Third, one could also combine the visual scanning process with auditory cues from the system that could
facilitate the identification of the target letters and eventually the response efficacy. An additional research issue could be
represented by the assessment of staff and caregivers’ views on the technology investigated in this study and variations
thereof. This could be done through social validation studies (Callahan, Henson, & Cowan, 2008).
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