Aug /Sep 23 Closing The Gap Solutions - Playing with Switches: Opening a World of Possibilities by Christoper Marotta and Loreto Dumitrescu
Playing with Switches: Opening a World of Possibilities accessibility & UDL Summary: Providing children with significant motor deficits with the ability to play, access their curriculum and control the environ- ment around them is a collaborative and important process. After reviewing key assessment and training methods, we will further explore this process starting with simple cause-and-effect adapted toy activation and moving into developing indepen- dence through access to computers and mobile devices.
INTRODUCTION Imagine it is your birthday, you're turning five years old, ev- eryone just sang, and it is time to open gifts. You open up boxes and boxes of gifts that include toys like a dancing cactus, a disco light, and a remote control car. What happens to that smile when those toys you just opened are not accessible because you have Cerebral Palsy and your hands do not have the required dexterity to activate the small little push button or toggle switch on the side of the toy? I did not realize what an adaptive switch can do beyond play- ing video games or battery-operated toys until I started working with a student with cerebral palsy at the Henry Viscardi School who had been an “access” challenge over the years. Each thera-
pist explored and tried many different devices and access points trying to find ways for him to access the curriculum, communi- cation devices, and leisure base activities. Once that point of ac- cess was determined, there was no stopping him from doing so much more than anyone ever imagined. Starting off with playing space invaders on the computer, listening to audiobooks and downloading movies on iTunes, and now ordering DoorDash. It all happens by pressing a simple adaptive switch. As disability professionals, we facilitate the use of assistive technology as a method to make play accessible. By removing barriers and providing necessary support, assistive technolo- gy allows individuals to engage in play activities that may have otherwise been inaccessible to them. The simplest method to
LORETO DUMITRESCU is an occupational therapist who has worked for the New York City Department of Education for over 20 years, providing both direct service as well as AT evaluations and previously provided early intervention services. Loreto received her MA in Educational Technology from Adelphi University where she is currently an Adjunct Professor teaching courses on assistive technology and Universal Design for Learning to pre-service educators. She co-founded Zero Day Camp, a non-profit on a mission to bring computer science and media literacy to youth and educators throughout New York City. Currently, she is a volunteer co- leader for the NY Metro chapter of Makers Making Change. loreto@zeroday.camp CHRISTOPHER MAROTTA is an occupational therapist who provides services to students with physical disabilities at the Henry Viscardi School in Albertson, NY. He has worked as an OT for over 20 years in a variety of settings, but his passion is assistive technology and enabling his students to be successful in and out of the classroom. Chris is an avid tinkerer and enjoys designing and fabricating adaptive devices. He shares his knowledge with others by lecturing occupational therapy students as an adjunct faculty member at Stony Brook University and Touro University. Christopher also presents and hosts workshops at national conferences and guest lectures at other schools and organizations. He is currently pursuing a doctorate in occupational therapy focusing on the impact of adapted sports on quality of life. Christopher is also volunteer co-leader of the NY Metro chapter of the Makers Making Change organization, where his goal is to teach others the skills of adapta- tion along with increasing awareness of disabilities. chrismarottaot@gmail.com
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accomplish this is by switch adapting. It begins with a basic in- expensive 3.5 mm mono jack or using something called a battery interrupter. Battery-operated toys like the ones you find in mall kiosks can be converted with this jack to allow the connection of any adaptive switch. Switch-adapted toys are specially modified toys that allow children with disabilities to operate them using an adaptive switch. These toys offer a range of benefits for children with disabilities, including increased independence, improved motor skills, and enhanced social interaction. These toys can be adapted to suit a wide range of disabilities, including those with limited mobility, vision or hearing impair- ments, and cognitive disabilities. The use of adapted toys can promote inclusion and help children with disabilities feel like they belong. Through adaptation, they can play with the same toys as their peers. Switch-adapted toys also provide a sense of control and inde- pendence, as they allow children to participate in play activities on their own terms and at their own pace, which can improve confidence and self-esteem. Adapted toys can also help to im- prove children's motor skills. By pressing a switch, children can develop their fine motor skills and hand-eye coordination. Finally, switch-adapted toys can promote social interaction among chil- dren with and without disabilities. By playing with the same toys, children can learn to communicate and play together, which can help to break down barriers and promote acceptance and un- derstanding of differences. Overall, assistive technology plays a crucial role in leveling the playing field, promoting engagement, and unlocking the potential for meaningful and enjoyable play for individuals with disabilities. It is beneficial to introduce the use of assistive technology at a very young age. Encouraging adaptive play for children with physical disabilities and/or are medically fragile is important in supporting learning cause-and-effect, and early use of technol- ogy can lead to so much more later in life. The ability to physi- cally touch a toy and turn it on is one of the first steps in looking at methods of access. There are two types of access methods, direct and indirect selection. Direct selection methods are more intuitive, fast, and efficient. Options may include means such as adapted styluses, adapted joysticks, adapted mice, head-track- ing cameras, and eye gaze systems. Indirect methods are more time-consuming and require more control, accuracy, and at- tention. Examples of ways to indirectly make selections can be through the use of a single switch, multiple switches, using voice commands, macros, and even Morse code. When working with students who have complex physical needs, there are times when using adaptive switches can be the only viable option as a method of access for that individual. An assistive switch in its most simple form is a single device that uses an audio cable connection that sends an activation signal to the connected toy/interface. This audio cable connection is the male counterpart to the 3.5 mm mono jack discussed earlier. There is a large variety of commercial options found on the market, from
companies like Ablenet, Enabling Devices, Inclusive Technology, and open source versions that can be created at home from the Makers Making Change (MMC) organization using off-the-shelf components. Every adaptive switch has the same function but they come in all shapes, sizes, and textures. Some require signif- icant force to activate and others none at all. It is through a de- tailed evaluation process that the most beneficial type of switch is identified. FINDING YOUR SWITCH: THE EVALUATION PROCESS One of the main focuses of occupational therapists and other disability professionals is to aid the user in determining the most efficient method of access. This evaluation process takes into con- sideration the student and all those involved in the student’s care, including parents, guardians, paraprofessionals, caregivers, nurs- es, therapists, and teachers. The evaluation process for assessing a student for switch access is not something that happens in a short time frame, it requires trial and error, data collection, and collaborative effort. The switch access relies on many factors, in- cluding the reliability of movement, examining time and accura- cy, intention and isolated control, endurance, and proper place- ment. Positioning is a key factor in having an appropriate switch site with ideal mounting being a key component. Identification of a reliable access site generally has a hierarchy of body parts to explore. It begins with more flexible parts of the body such as the hands, head, and mouth to more restricted parts such as the feet, and upper and lower extremities, and ends with using mus- cle and brain signals. Each part has its own unique qualities and features that allow for greater versatility with access.
Switch location hierarchy chart
Below you will find a chart that provides examples of what each body part may look like for a switch user.
Hands
Head Mouth Feet
Upper
Lower
Mind
Tap a mi-
Tap a small specs switch with the right side temple of the head.
Activate a sip-and- puff switch with breath support.
Tap on a large pedal switch.
Activate a jelly bean switch by elevating the shoulder.
Tap a pal pad switch with the
Activate a brain-com- puter interface (BCI) via EEG
crolite switch with an index finger.
inside of the knee.
to select a desired letter.
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Another important aspect of learning to utilize a switch in- cludes using proper verbal, visual, and physical cues to foster a student's understanding. Saying to a student “Hit the switch” or “Tap the button” may inhibit the student from learning the causal relationship of activating the switch. It is vital to connect the switch action with a functional outcome and to encourage the function (turn on a toy, type a letter on a computer, tap on a tablet, or select a “Hi, how was your weekend?” on a commu- nication device). The evaluation process must include intrinsic motivation and take into account who the user is. Data collection is a principal aspect of determining the cor- rect switch choice and proper placement. There are multiple tools and strategies that are available to aid in this process. A team may begin with a simple document or spreadsheet table that collects response times based on various conditions.
widely used motivators is switch-adapted toys. There are various commercially available options of toys that may be purchased online from companies like Enabling Devices, Ablenet, Inclusive Technology, or from sellers on Amazon and Etsy. The high cost of commercially obtained toys can be a considerable barrier for most individuals with disabilities and their families. Like all children, a variety of toys and ongoing novelty are important to maintain, making purchasing more burdensome. As discussed earlier, simple battery-operated toys can be modified or switch-adapted using an inexpensive basic 3.5 mm mono jack cable and a bit of soldering skills. Various orga- nizations support access to these toys or provide instructions on how to modify them. Makers Making Change, FairPlay, and Switched are examples of some organizations found nationally that support the mission to create accessible play opportunities. They host workshops, hold hackathons, and create free instruc- tional manuals and videos to teach others to adapt. Continuing to develop play skills, users may move beyond smaller toys, and explore other switch-adapted devices. Devic- es such as adapted Uno Attack, Nerf guns, card shufflers, dice rollers, and even switch-operated bowling ramps are some examples. Single switch presses may even be used to support adapted mobility projects such as Go Baby Go. This same cause- and-effect skill can transfer to the control of an environment to turn a fan, appliance, light, or music source on or off. Switch presses may also be used for single message communication buttons as a form of Alternative Augmentative Communication (AAC) systems.
Able to wait
Able to activate
Able to hold
Able to release
Able to activite again
Right hand
Left hand
Head
Right knee
Sample table used to collect data on the access point and its responses
Moving from there, there are a variety of software systems available that automatically collect speed and accuracy data. These include software such as Koester Performance Research’s Compass or the free web-based application, Scanning Wizard. Scanning Wizard provides switch users, practitioners, and care- givers recommendations to optimize switch and scanning set- ups. GETTING STARTED Once the optimal switch, access method, and location are identified, it is time to get to work! Switch progression is a grad- ed method of introducing switch access and developing scaf- folded proficiency. Most often, users begin with simple cause- and-effect activities; pressing the switch to engage with a toy, learning to press it again, or holding the switch for prolonged periods. The next development would include introducing two or more switches that provide differing effects followed by the introduction of timing. This would involve waiting for a partic- ular event to occur before pressing the switch. All these skills build a user’s ability to then complete formal scanning where items are scanned through with switch activation on the desired item. Mastering the ability to scan can open the user to a wide range of mobile and computer access, which is the ultimate goal. When first developing cause and effect skills, one of the most
Example of an adapted Uno Attack for switch use.
DEVELOPING SKILLS FOR LIFE Once establishing many of these foundational cause-and-ef- fect skills and developing the understanding and independence of being able to affect their environment, users can begin ex- perimenting with mobile and computer access. A key interme- diary between switches and computers is a switch interface.
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This device does the important work of converting the switch activation signal into information the computer can under- stand. Most commonly, these devices convert the signal to a keyboard keystroke but may also send a mouse button press, or media control. There are a wide variety of commercial devices and open-source versions available. The choice depends on the needs of the individual, the type of device being used, and the cost. Features of the switch interface boxes include the ability to customize the keystrokes being sent, connection methods (wired/USB or wireless/Bluetooth), and the number of ports and connections. A more recent and exciting innovation has de- veloped in providing access to highly customized interactions through the use of microcontroller boards such as Makey Makey and Microbit. These boards can send keystrokes to the computer by connecting two conductive surfaces to close a circuit and use alligator clips to create these connections, lowering the entry barrier. This solution type is lower in cost and may serve as an effective prototyping mechanism.
The Hitch switch interface box connected to the computer using Smart Notebook as a classroom dice roller when playing a math board game in the classroom.
porting their role as a student and providing literacy solutions is key. Switch access may be used to engage in learning activities created using familiar software such as PowerPoint and Goo- gle Forms when using an iPad tablet. Engaging games such as Breakout Rooms and MadLibs may be interacted with. Switch control may also allow the student to read and navigate through digital books available from a wide range of web apps and mo- bile apps which include: Voice Dream Reader, iBooks, Libby, Tar- heel Reader, and Tumble Books. Literacy software such as Click- er, support a switch-friendly method of writing and navigating through books. Cricksoft’s Clicker writing application interface allows for both automatic and step scanning incorporating audi- tory feedback and word bank options. Additional software such as Grid3, HelpKidzLearn, and Inclusive TLC software provides a more scaffolded learning environment and access to literacy through customizable learning activities. Written responses are most often completed through the use of the onscreen keyboard available on all operating systems. Al- ternatively, if a user can memorize Morse code, typed print may be produced using switch control for dots and dashes leading to a faster rate of keyboarding when compared with onscreen keyboard scanning. Customized 3rd party onscreen keyboards are also available providing a chunked scanning method (Crik- soft’s Superkeys), word prediction support, and customized vi- sual presentations (Keeble). Being able to tell someone “I’m hungry” or “I’m in pain”, is cru- cial for individuals who do not communicate using traditional speech. In many cases, that person who is unable to speak clear- ly also has complex access issues where using switches may be the most appropriate option. Switch scanning capabilities are built into all AAC devices and programs found on the market, and offer the ability to customize timing and feedback. For iP-
An additional and important aspect to consider is the built- in accessibility settings within the operating system. The Ap- ple Mac and iOS operating systems have robust and complex settings to support computer-wide access using even a single adaptive switch without additional software. Google Chrome- books and Android devices have also added built-in switch ac- cessibility. Windows operating systems, however, do not have switch accessibility settings and require the purchase and instal- lation of additional software that may provide this functionality. The only switch accessibility found in Windows is in the built-in onscreen keyboard. RJ Cooper developed a mouse alternative called CrossScanner, which enables a switch user to use one or two switches to navigate a mouse cursor. FROM WRITING TO RIDING. Now having selected the optimal setup, the user is ready to explore the world and the possibilities that having access to computers and mobile devices offer. For younger users, sup- An example of the Makey Makey board connected to a computer with the ground wire clipped to a metal bracelet and the input wire clipped to a metal measuring cup. The circuit is activated once the user lightly touches the cup.
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ad-based AAC apps, users may choose to use the switch settings available on either the operating system level or within the app. Controlling one's environment and engaging in leisure is a way to further develop independence. With the rise of connect- ed and smart home technologies, the ability to control so much of the home environment is now possible using these same switches at a much lower cost than previously available. Devices such as the PowerLink, provide the user the ability to activate appliances throughout the home. Most smart home devices also come with companion apps that can be switch-activated providing an additional method of controlling the environment. Switching TV channels and viewing options as well as selecting and playing music is now readily possible using the accessibility settings within AppleTV or connecting devices such as the Puck to navigate a TV that does not have “smart” capabilities. These same systems also allow the user to scan through apps to order groceries and takeout. Switch navigating through apps allows individuals to not only use this technology as a consumer but become a creator. Switch control may be used for visual creativity such as photography, video recording/editing, and digital arts such as graphic design using more complex switch gestures on iOS. Music creation us- ing commercially available apps and exploring keyboard-acces- sible websites such as Experiments with Google provides new opportunities for expressing creativity. Creating social connections outside of the caregiver network is now possible through the growing world of adaptive gaming. One of the most popular accessibility devices for gaming, the Adaptive Controller, was developed by Xbox to support switch access. This device also features Copilot which allows a compan- ion to navigate the joystick while the user activates the switch as a button presses. The success of this device is leading other con- sole developers to follow suit and create their own hardware. Playstation recently announced Project Leonardo, an accessible controller with four 3.5mm AUX ports to support a variety of external switches and third-party accessibility accessories. A di- verse number of organizations such as AbleGamers are working towards breaking down barriers in this world of adaptive gam- ing both on the hardware and software side. Although most console games may be fast-paced and com- plex for emerging gamers, some entry-level options are available via games from HelpKidzLearn, web-based games, and through purchases from vendors like Marblesoft. Additionally, there are a few web-based platforms like Scratch and Makecode Arcade that are available to allow for the custom creation of games us- ing block-based code to adjust for many gaming variables like timing, visual complexity, and activation methods. These plat- forms allow games to be played on any computer or mobile device and are keyboard and switch accessible if programmed correctly. Requesting an Uber or other rideshare using switch scan- ning can certainly be done, but the logistics of finding an ac-
cessible van may be a barrier. However, it is possible to drive a power wheelchair using single, two, or even an array of adaptive switches. Two examples of switch use for power mobility are us- ing a head array which is made of three proximity switches and using a sip and puff switch. CLOSING It is not every day or even every year that you have that mo- ment when someone you are working with can do something independently using assistive technology. Sometimes the sim- plest click of a switch, tap of a button, or blink of an eye can open the door to pathways of possibilities. It is important as clinicians to encourage early learning accessible play and consider the use of adaptive switch technology as it can provide that hope that someone is looking for to give them access to the world of inde- pendence they truly deserve. We would like to leave you with a poem written by Kiley McDonnell, a student at the Henry Viscar- di School, describing her journey through this process:
BUTTERFLY BY KILEY I felt sad I was stuck I could think But couldn't move People talked around me About me As if I weren’t there But I was there Listening and learning Unable to say a word. I could move my eyes Raise my brow And hope the answer Was a Yes or No Then someone came And broke me free To flick a finger Move a knee I learnt to scan Click a switch Change TV channels Music stations Facetime grandma Use You Tube I now have ways to talk By tweet and text Use my device To Explore To Connect And Express My thoughts are unique Experiences too I soar in JOY As my world expands I feel special I feel free Glad to be free Glad to be me I could see the world Now the world sees me
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