People Using Switches
People who use switches may face a more challenging task than peers who are physically able to directly select (VANDERHEIDEN G. 1976; HARRIS D. & VANDERHEIDEN G. 1980; McDONALD E. 1980; HARRIS D. 1982; SHANE H., LIPSCHULTZ R., & SHANE C. 1982; SAYA M., PELIKAN Y., & BARR L. 1984; VANDERHEIDEN G. 1984; GUNDERSON J. 1985;VANDERHEIDEN G. & LLOYD L. 1986; BLACKSTONE S. 1989; LIGHT J. 1989; FRIED-OKEN M., HOWARD J., & STEWART S. 1991; RATCLIFF A. 1994; WHITTLE H. & TOWNEND S. 1995)
Researchers and clinicians, as well as users, all agree that scanning is a complex task involving a variety of components, including motor, visual-perceptual, cognitive, and linguistic skills (RATCLIFF A. 1994)
People who use switches are likely to be both non-ambulant and more severely physically impaired than people who are able to directly access an augmentative communication system. This should not necessarily single them out for differential treatment. However, as the task is seemingly more arduous and the communicative process takes longer, certain strategies may be undertaken and allowances made to ensure that the opportunity to grow in competence and confidence is maximised. While everything in this manual is equally relevant to people who use switches some special strategies are outlined in the section below.
Researchers and clinicians, as well as users, all agree that scanning is a complex task involving a variety of components, including motor, visual-perceptual, cognitive, and linguistic skills (RATCLIFF A. 1994)
People who use switches are likely to be both non-ambulant and more severely physically impaired than people who are able to directly access an augmentative communication system. This should not necessarily single them out for differential treatment. However, as the task is seemingly more arduous and the communicative process takes longer, certain strategies may be undertaken and allowances made to ensure that the opportunity to grow in competence and confidence is maximised. While everything in this manual is equally relevant to people who use switches some special strategies are outlined in the section below.
SWITCH 2 - Task and discussion sheet
Work through the tasks given (approximately ten minutes should be sufficient). The differences may include:
C ease of use;
C speed of use;
C may require longer to respond;
C physical strain involved;
C layout of symbols may be different;
C may require more prepared sentences (rather than words);
C may require a different response strategy;
C experience may be different;
C may have greater frustration;
C may be frustrated if compared to direct selectors;
C the switch user may require fewer symbols to speed access;
C the switch user may require switch training before operating an AAC system;
C may have different accessing methods for different devices;
C is unlikely to be ambulant.
Using the ideas generated work through all (or selected) statements in the discussion sheet. Do the staff agree or disagree with the statements? Do the statements raise any interesting issues? Can the statements be related to a known pupil or student?
C ease of use;
C speed of use;
C may require longer to respond;
C physical strain involved;
C layout of symbols may be different;
C may require more prepared sentences (rather than words);
C may require a different response strategy;
C experience may be different;
C may have greater frustration;
C may be frustrated if compared to direct selectors;
C the switch user may require fewer symbols to speed access;
C the switch user may require switch training before operating an AAC system;
C may have different accessing methods for different devices;
C is unlikely to be ambulant.
Using the ideas generated work through all (or selected) statements in the discussion sheet. Do the staff agree or disagree with the statements? Do the statements raise any interesting issues? Can the statements be related to a known pupil or student?
SWITCH 3 - One thing at a time
To reduce the skill requirements and thus simplify a scanning technique during the initial stages of intervention, training should be conducted utilizing a layering approach. When using a layering approach, intervention is initially directed toward training the motor skills dictated by scan mode. As the child gains proficiency with scan mode, the additional skill requirements of scan pattern are gradually and systematically added to the training task. Ultimately, a cognitive and communication load (purposely minimized in the previous layers) is overlayed on the motor and visual requirements of the scanning task. (CRAIN S. & GOOSSENS C. 1990 page 18)
If an electronic communication aid is introduced before the individual has the switch control and understanding of the scan there is a risk of them becoming frustrated and rejecting the aid. (WHITTLE H. & TOWNEND S. 1995)
If the switch is new to the person there is much work to be done before the AAC system should be introduced. Work may centre on teaching the individual how, when, and why to use the switch. This may be achieved with simple technology and/or basic computer programs designed specifically for the purpose. Asking a person to concentrate on hitting the switch at the correct time, on the scanning procedure used by the AAC system, on the visual-perceptual aspect of the AAC system’s overlay, and on building a phrase from selected vocabulary will likely be too much for the novice switcher. Crain and Goossens detail motor, visual, cognitive, and communicative aspects of scanning (CRAIN S. & GOOSSENS C. 1990). It shouldn’t be surprising that all of these skills, when presented simultaneously, represents a switching overload! Learning to use a switch should not be a chore. It should be kept simple and it should be fun (see LEVIN J. & SCHERFENBERG L. 1994). Take one step at a time, and keep to one scanning pattern with one switching system (See PICHÉ L. & REICHLE J. 1991) with access to all devices.
Because school-aged children are expected to use their communication systems to participate in a variety of tasks and activities during the school day, it is important to understand the relative demand of the access method, so as not to place too much on the users at one time. (RATCLIFF A. 1994)
Overall, the results of this study confirm the clinical practice of minimizing the cognitive, visual, and communicative demands on the initial trial tasks in assessing scanning access for AAC system use. This may mean using tasks and equipment other than the actual AAC equipment. (RATCLIFF A. 1994)
If an electronic communication aid is introduced before the individual has the switch control and understanding of the scan there is a risk of them becoming frustrated and rejecting the aid. (WHITTLE H. & TOWNEND S. 1995)
If the switch is new to the person there is much work to be done before the AAC system should be introduced. Work may centre on teaching the individual how, when, and why to use the switch. This may be achieved with simple technology and/or basic computer programs designed specifically for the purpose. Asking a person to concentrate on hitting the switch at the correct time, on the scanning procedure used by the AAC system, on the visual-perceptual aspect of the AAC system’s overlay, and on building a phrase from selected vocabulary will likely be too much for the novice switcher. Crain and Goossens detail motor, visual, cognitive, and communicative aspects of scanning (CRAIN S. & GOOSSENS C. 1990). It shouldn’t be surprising that all of these skills, when presented simultaneously, represents a switching overload! Learning to use a switch should not be a chore. It should be kept simple and it should be fun (see LEVIN J. & SCHERFENBERG L. 1994). Take one step at a time, and keep to one scanning pattern with one switching system (See PICHÉ L. & REICHLE J. 1991) with access to all devices.
Because school-aged children are expected to use their communication systems to participate in a variety of tasks and activities during the school day, it is important to understand the relative demand of the access method, so as not to place too much on the users at one time. (RATCLIFF A. 1994)
Overall, the results of this study confirm the clinical practice of minimizing the cognitive, visual, and communicative demands on the initial trial tasks in assessing scanning access for AAC system use. This may mean using tasks and equipment other than the actual AAC equipment. (RATCLIFF A. 1994)
SWITCH 4 - It is possible to have too much of a good thing
As the cartoon suggests, having one set of switches to control all items is generally better than a different set of switches for each item. It is possible to have a person control many items (drive the chair, control an AAC system, operate a computer, control the environment, etc) through one set of switches (single, dual, or treble). The ‘Eight by Eight’ system (contact Colin Clayton at the Wolfson Centre) is one such piece of technology.
If two sets of switches must be used then the scanning pattern used on both sets should be identical. If one set uses an inverse row/column scan with a manual entry and another an automatic quadranting column/row there is likely to be confusion. Indeed, the same is true of one set of switches being used to operate several items of technology. If the computer and the communication device (for example) do not have identical scanning arrangements then the task is made more demanding for the switch user. Ideally, the motoric aspect of switching should become automatic (think of touch typing) so that the switch user can concentrate on the task in hand.
An increasing number of high-tech AAC systems offer additional facilities including environmental control, keyboard emulation to all major computers, and connection to peripherals such as printers. The switch operating the AAC device will operate all the others.
I am concerned that as the technology gradually improves and as high-tech augmentative communication devices are designed to do more and more things that people will be seduced by the technology rather than looking to the primary goal - communication. I am as guilty as the next person for buying a hi-fi system or a video with the most gadgets and knobs and then never making any use of them. If a system is purchased because it contains the latest six-stacking ten-speed cd player then communication has lost out to technology. However, this is not to say that high-tech augmentative communication devices should not be able to do other things to enable and thus empower the user - they should - but communication must be the primary focus.
If two sets of switches must be used then the scanning pattern used on both sets should be identical. If one set uses an inverse row/column scan with a manual entry and another an automatic quadranting column/row there is likely to be confusion. Indeed, the same is true of one set of switches being used to operate several items of technology. If the computer and the communication device (for example) do not have identical scanning arrangements then the task is made more demanding for the switch user. Ideally, the motoric aspect of switching should become automatic (think of touch typing) so that the switch user can concentrate on the task in hand.
An increasing number of high-tech AAC systems offer additional facilities including environmental control, keyboard emulation to all major computers, and connection to peripherals such as printers. The switch operating the AAC device will operate all the others.
I am concerned that as the technology gradually improves and as high-tech augmentative communication devices are designed to do more and more things that people will be seduced by the technology rather than looking to the primary goal - communication. I am as guilty as the next person for buying a hi-fi system or a video with the most gadgets and knobs and then never making any use of them. If a system is purchased because it contains the latest six-stacking ten-speed cd player then communication has lost out to technology. However, this is not to say that high-tech augmentative communication devices should not be able to do other things to enable and thus empower the user - they should - but communication must be the primary focus.
SWITCH 5 - Keep a photography handy
Is there such a thing as an optimal position? Karen Kangas (KANGAS K. 1990) says not. We are all always on the move. We rarely sit perfectly still even for an instant:
As humans, we do not have optimal positions, we change positions all day, every moment, even when we sleep. (KANGAS K. 1990 page 64)
Wrong! There is no best position, because there is no position. Singular! There are multiple positions, multiple situations, multiple interactions. Therefore we need to be able to look at how to assist our students in discovering methods of success that they can initiate and use any way they feel like in order to augment their communication. (KANGAS K. 1990 Page 63)
His overall tone differed from day to day, making optimal switch placement difficult as attempts were made to accommodate his changing tone. (OSBORNE S. & McLAUGHLIN L. 1993 page 97)
Positioning a switch (a communication system or a user) would appear to be a very tricky task and is a job for a multi-disciplinary team of occupational therapist, physiotherapist, speech professional, rehabilitation engineer, teacher, carer and significant others. It is frustrating to make a decision in isolation only to find that another member of the team finds the (switch) position inconvenient or obstructive, for example, if it has to be (re)moved for a tray at meal times. Finding the optimal position (if there is such a thing) may require an extensive trial and error period in which a switch user is given time to get used to the new motoric, cognitive, visual, and (perhaps) emotional skills involved in the task (For optimal positioning see KANGAS K. 1990; OSBORNE S. & McLAUGHLIN L. 1993; TOWNEND S. 1996;). Sometimes after a user has made a few fumbling efforts at accessing a switch in what we think might be a good position, it is assumed that the selected location is inappropriate. We give up too easily. Learning the new skills involved takes time and practice and, therefore, motivation. Why should the user try to hit the silly thing if she or he doesn’t have a good reason? Again, as recommended in SWITCH 3, we should target one thing at a time; we need to provide a simple but motivational use for a switch (turning music on and off for example) so that the user will make the attempt. We should then monitor the use of the switch over a period to see if there is an improvement. How long should we wait before we say ‘enough is enough’? Kangas suggests a minimum of 100 attempts:
No, I am not kidding. Most of us do not learn anything without trying it 1,000 times, or 10,000 times, so I am asking for only 100. 10 is not enough. (KANGAS K. 1990 page 65)
This is not to say a position a user wants to change or which causes a user a great deal of frustration should be completely disregarded:
Leave them alone and watch them for 100 times. If a student does not ask to have it changed, leave it alone. If they continue to attempt or can use it, leave it alone. If they are frustrated, change it. If they request it change it. But please, don’t change it all the time, and in small amounts every day as if it were yours. Again, students need opportunities for success and mistakes. They need control of their systems and often we negate their communication power by controlling their aids. (KANGAS K. 1990 page 68)
A multi-disciplinary team is likely to select a position that has a reasonable chance of success as they will know the user and what may be possible. Thus, allowing the user a couple of days to become familiar with this new addition to his or her wheelchair (or wherever) seems a reasonable thing to do.
Once we have found the optimum ‘optimal’ position for a switch it must stay there. It is no use if it moves away when the user hits it. There are a number of switch mounting systems commercially available (AbleNet arms, Mobilia systems, PRC goosenecks, and Tash mounts - to name but four. See the suppliers list at the beginning of this manual for addresses). Many establishments engineer their own.
To position a switch, which has to be moved from time to time, correctly, frontal and side elevation photographs should be taken of the optimum position. These can be displayed on the user’s chair such that people can make the correct alignment each time the switch has to be re-positioned after a move.
The photographs should display the optimum seating position of the user. If the user is significantly out of the optimum position the photographs can be used to remind the user to correct his or her seating position. The photographs should be of a happy, smiling user. A user is unlikely to emulate a picture which depicts unhappiness and pain.
Switch systems often comprise several elements: the switch; a lead; a clamp; a mount; etc. Significant others can often be found searching for an important element of a system which has gone missing. As switch users are likely to be slower than their peers who are able to directly select, it is important not to waste time searching for system components. A system inventory attached to the user’s chair may prove to be a good idea. Each element can be photographed and the photographs pasted into a ‘user’s notebook’. The system inventory serves as a reminder to all significant others that these items must travel with a user. If new staff are working with a user they can refer to the photographs for guidance if they are unsure about the system inventory items. The system inventory could also be laminated and positioned discretely on the user’s chair.
Note: Some users may not like photographs or an inventory being attached in a prominent position to their chair. If this is the case, the photographs and inventory could form part of a communicative information manual which is placed discretely in a bag at the rear of the user’s chair. There is no guarantee that staff will refer to such a manual but they have no excuse for poor switch positioning or missing system parts if they are aware of its existence.
CASE STUDY: A student was being assessed for a new piece of equipment. However, it was found that both the lead to his switch and his glasses had gone missing. Not only did the search for these items take some considerable time but the student became agitated and was not able to be properly assessed.
Staff should be educated to understand:
C the importance of switch systems;
C how switch systems work;
C the different elements of a particular user’s switch system;
C the correct way to handle and to connect the various parts of a user’s switch system;
C the adjustment and correct positioning of a user’s switch system.
However, even when all the above steps have been carried out, things still may not work as predicted and it may be necessary to alter the switching system itself:
CASE STUDY: A switch mount was continually and mysteriously being broken. The facilitator decided to investigate. She found that some staff found the adjustment to the mount too difficult and twisted the switch out of the way by brute force. It was necessary for them to relocate the switch to move the individual (for toileting etc.) several times each day. The problem was resolved by repositioning and redesigning the mount such that the topmost part could easily be swivelled backwards out of the way and then repositioned exactly. It was easier to change the mount than the staff!
Providing the end result is the same, sometimes it is more appropriate to redesign the system to accommodate the needs of the staff as well as the needs of the user rather than continuing to fight a losing battle!
As humans, we do not have optimal positions, we change positions all day, every moment, even when we sleep. (KANGAS K. 1990 page 64)
Wrong! There is no best position, because there is no position. Singular! There are multiple positions, multiple situations, multiple interactions. Therefore we need to be able to look at how to assist our students in discovering methods of success that they can initiate and use any way they feel like in order to augment their communication. (KANGAS K. 1990 Page 63)
His overall tone differed from day to day, making optimal switch placement difficult as attempts were made to accommodate his changing tone. (OSBORNE S. & McLAUGHLIN L. 1993 page 97)
Positioning a switch (a communication system or a user) would appear to be a very tricky task and is a job for a multi-disciplinary team of occupational therapist, physiotherapist, speech professional, rehabilitation engineer, teacher, carer and significant others. It is frustrating to make a decision in isolation only to find that another member of the team finds the (switch) position inconvenient or obstructive, for example, if it has to be (re)moved for a tray at meal times. Finding the optimal position (if there is such a thing) may require an extensive trial and error period in which a switch user is given time to get used to the new motoric, cognitive, visual, and (perhaps) emotional skills involved in the task (For optimal positioning see KANGAS K. 1990; OSBORNE S. & McLAUGHLIN L. 1993; TOWNEND S. 1996;). Sometimes after a user has made a few fumbling efforts at accessing a switch in what we think might be a good position, it is assumed that the selected location is inappropriate. We give up too easily. Learning the new skills involved takes time and practice and, therefore, motivation. Why should the user try to hit the silly thing if she or he doesn’t have a good reason? Again, as recommended in SWITCH 3, we should target one thing at a time; we need to provide a simple but motivational use for a switch (turning music on and off for example) so that the user will make the attempt. We should then monitor the use of the switch over a period to see if there is an improvement. How long should we wait before we say ‘enough is enough’? Kangas suggests a minimum of 100 attempts:
No, I am not kidding. Most of us do not learn anything without trying it 1,000 times, or 10,000 times, so I am asking for only 100. 10 is not enough. (KANGAS K. 1990 page 65)
This is not to say a position a user wants to change or which causes a user a great deal of frustration should be completely disregarded:
Leave them alone and watch them for 100 times. If a student does not ask to have it changed, leave it alone. If they continue to attempt or can use it, leave it alone. If they are frustrated, change it. If they request it change it. But please, don’t change it all the time, and in small amounts every day as if it were yours. Again, students need opportunities for success and mistakes. They need control of their systems and often we negate their communication power by controlling their aids. (KANGAS K. 1990 page 68)
A multi-disciplinary team is likely to select a position that has a reasonable chance of success as they will know the user and what may be possible. Thus, allowing the user a couple of days to become familiar with this new addition to his or her wheelchair (or wherever) seems a reasonable thing to do.
Once we have found the optimum ‘optimal’ position for a switch it must stay there. It is no use if it moves away when the user hits it. There are a number of switch mounting systems commercially available (AbleNet arms, Mobilia systems, PRC goosenecks, and Tash mounts - to name but four. See the suppliers list at the beginning of this manual for addresses). Many establishments engineer their own.
To position a switch, which has to be moved from time to time, correctly, frontal and side elevation photographs should be taken of the optimum position. These can be displayed on the user’s chair such that people can make the correct alignment each time the switch has to be re-positioned after a move.
The photographs should display the optimum seating position of the user. If the user is significantly out of the optimum position the photographs can be used to remind the user to correct his or her seating position. The photographs should be of a happy, smiling user. A user is unlikely to emulate a picture which depicts unhappiness and pain.
Switch systems often comprise several elements: the switch; a lead; a clamp; a mount; etc. Significant others can often be found searching for an important element of a system which has gone missing. As switch users are likely to be slower than their peers who are able to directly select, it is important not to waste time searching for system components. A system inventory attached to the user’s chair may prove to be a good idea. Each element can be photographed and the photographs pasted into a ‘user’s notebook’. The system inventory serves as a reminder to all significant others that these items must travel with a user. If new staff are working with a user they can refer to the photographs for guidance if they are unsure about the system inventory items. The system inventory could also be laminated and positioned discretely on the user’s chair.
Note: Some users may not like photographs or an inventory being attached in a prominent position to their chair. If this is the case, the photographs and inventory could form part of a communicative information manual which is placed discretely in a bag at the rear of the user’s chair. There is no guarantee that staff will refer to such a manual but they have no excuse for poor switch positioning or missing system parts if they are aware of its existence.
CASE STUDY: A student was being assessed for a new piece of equipment. However, it was found that both the lead to his switch and his glasses had gone missing. Not only did the search for these items take some considerable time but the student became agitated and was not able to be properly assessed.
Staff should be educated to understand:
C the importance of switch systems;
C how switch systems work;
C the different elements of a particular user’s switch system;
C the correct way to handle and to connect the various parts of a user’s switch system;
C the adjustment and correct positioning of a user’s switch system.
However, even when all the above steps have been carried out, things still may not work as predicted and it may be necessary to alter the switching system itself:
CASE STUDY: A switch mount was continually and mysteriously being broken. The facilitator decided to investigate. She found that some staff found the adjustment to the mount too difficult and twisted the switch out of the way by brute force. It was necessary for them to relocate the switch to move the individual (for toileting etc.) several times each day. The problem was resolved by repositioning and redesigning the mount such that the topmost part could easily be swivelled backwards out of the way and then repositioned exactly. It was easier to change the mount than the staff!
Providing the end result is the same, sometimes it is more appropriate to redesign the system to accommodate the needs of the staff as well as the needs of the user rather than continuing to fight a losing battle!
SWITCH 6 - People who use switches should not be left out
Randy was placed in a vocational skills class for the mentally retarded. Since he was the only physically challenged student in that class, he spent his day watching the other students complete life skills tasks. (McNAIRN P. 1995 page 74)
Because a person will never do, does not mean that a person should never experience. While it is probably true that a person with a severe disability affecting all four limbs may never bake a cake without some assistance, it does not mean the person should miss this aspect of the curriculum in favour of something else. The emphasis (as has already been stressed) should be on participation and experience. People who use switches can control electronic devices in a kitchen (see LEVIN J. & SCHERFENBERG L. 1994). The individual has much to gain by smelling, feeling, tasting, hearing, seeing, experiencing, and participating in every aspect of baking a cake. What does it matter if there is a mess? What does it matter if the individual is in a mess?
Providing there is no danger:
Do
not
eliminate
-
participate
Participation is the only prerequisite to communication. Without participation, there is no one to talk to, nothing to talk about, and no reason to communicate. For young children, the primary participation context is play. (BEUKELMAN D. & MIRENDA P. 1992 page 177)
People who use switches should not be left out. Create a ......
Because a person will never do, does not mean that a person should never experience. While it is probably true that a person with a severe disability affecting all four limbs may never bake a cake without some assistance, it does not mean the person should miss this aspect of the curriculum in favour of something else. The emphasis (as has already been stressed) should be on participation and experience. People who use switches can control electronic devices in a kitchen (see LEVIN J. & SCHERFENBERG L. 1994). The individual has much to gain by smelling, feeling, tasting, hearing, seeing, experiencing, and participating in every aspect of baking a cake. What does it matter if there is a mess? What does it matter if the individual is in a mess?
Providing there is no danger:
Do
not
eliminate
-
participate
Participation is the only prerequisite to communication. Without participation, there is no one to talk to, nothing to talk about, and no reason to communicate. For young children, the primary participation context is play. (BEUKELMAN D. & MIRENDA P. 1992 page 177)
People who use switches should not be left out. Create a ......
SWITCH 7 - People Participation Permit
The PPP is a philosophy rather than just a piece of paper as the cartoon might suggest. It is an attitude, a belief, a necessity, and a right. Without it people will miss out on much that is essential to growth:
A disabled child has the right to enjoy a full and decent life, in conditions which ensure dignity, promote self-reliance, and facilitate the child’s participation in the community. (UN CONVENTION ON THE RIGHTS OF THE CHILD 1989)
If a child with disabilities is to have every opportunity to grow up with similar perceptions of the world as his non-disabled peers, full involvement with everyday activities is essential. The child already has a disadvantage in that he has a disability. Too much segregation and ‘specialised activity’ increase this disadvantage by setting him farther apart from his peers. (STANTON M. 1992)
To develop people must participate
A disabled child has the right to enjoy a full and decent life, in conditions which ensure dignity, promote self-reliance, and facilitate the child’s participation in the community. (UN CONVENTION ON THE RIGHTS OF THE CHILD 1989)
If a child with disabilities is to have every opportunity to grow up with similar perceptions of the world as his non-disabled peers, full involvement with everyday activities is essential. The child already has a disadvantage in that he has a disability. Too much segregation and ‘specialised activity’ increase this disadvantage by setting him farther apart from his peers. (STANTON M. 1992)
To develop people must participate
