Designing for People with Cognitive Disabilities in Language and Literacy


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UXPA 2013 Annual Conference Wednesday July 10, 2013 11:00am - 12:00pm ET by Yulia Nemchinova

The importance of accommodating visually impaired Web users is now widely recognized - yet cognitively impaired users are still largely left behind. Cognitive disabilities include conditions such as learning and language disabilities, attention disorders, traumatic brain injury, mental retardation, autism, cerebral palsy, cognitive issues related to aging and more. The broad spectrum of cognitive issues and lack of user research and evaluation pose immense and important challenges to us as UX practitioners. This presentation addresses design for this diverse user group, with a special focus on language and literacy disabilities fairly common in both adults and kids.

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  • I teach a usability engineering class and I get request for accommodating a student with disability. One complication: it is an online class, so I don’t get to see my students until the very end when they present their findings. As as Uxer I believe we need to know our audience if we really wants to help.
  • I was still at a loss in identifying the disability and ultimately how I could help. Could you guess what the disability was?
  • The student came forward and finally disclosed his disability as he failed his first assignment. It is hard to come forward and talk about your disability unless you absolutely have to. I felt that this was my own failure, even though the system is setup in such a way that failure is not a surprising result.
  • I am Yulia Nemchinova. I have been always fascinated by human cognition. Lucky for me, last year I was asked to do a lit research how we can better accommodate people with cognitive disabilities as the agency. I hope we can have a dialog and share what is being done.
  • The expectations and the task for this research was to find out what others are doing in providing better access to:The agency I work for daily interacts with people that have cognitive impairments whether it is via the Web, in person at numerous Field Offices, by telephone, at kiosks, or print publications. The focus remained the first two.
  • There are more people that live with a disability or deal with a disability of someone close to them than we can possibly imagine. This is a lot of people that need help!
  • Cognitive disabilities include conditions such as learning and language disabilities, attention disorders, traumatic brain injury, mental retardation, autism, cerebral palsy, cognitive issues related to aging and more. Many of these impairments are invisible especially in a mild form. This classifies CD by their clinical diagnoses while from the UX perspective, we are mostly interested in how it impacts the experience and interaction.
  • The impact of cognitive disabilities on human cognition is just as diverse its spectrum and affects memory, attention, language and reading, emotional control, speed of reasoning, executive functions to name a few. Francik (1999) provided a wonderful classification that is widely cited and is indeed helpful.
  • Remember my student who did not wish to disclose anything about his disability? “When it comes to needs assessment more often than not people with disabilities prefer not to disclose it or they don’t know what their disability is.”Nancie Payne, PhDConsultant, Payne & Associates, Inc.
  • Cognitive disabilities can be combined with physical ones.
  • The causes for this situation include several high profile cases of patients’ abuse in mental institutions. It is now known, that from the mid-1950s to late-1970s during medical studies, patients with cognitive disabilities at Willowbrook State School in New York City and other mental institutions were mistreated. While including people with cognitive limitations in user research studies happens very rarely if at all, there are a number of advocacy groups that have access to individuals with cognitive impairments and are willing to assist organizations with improving the quality of life for the cognitively disabled.
  • This apparently common sense rules are being broken more often than not.
  • If for most of users, there is a workaround, for those with cognitive disabilities it is a real showstopper.
  • Blindness remains the priority for accessibility researchersLack of research on the usability engineering methods suitable for users with cognitive disabilitiesLimited representation of cognitive impairments within the accessibility communityVery little testing has been conducted
  • JAWS by Freedom ScientificWindow EyesZoomtextvyaisquaredBrowseAloud by TextHelpRead&Write by TextHelpVoiceOver for iPhone
  • Universal Design or Barrier Free Design: bus lowered to the ground
  • Universal Design: Curb side access
  • Ramps
  • As a barrier free design
  • What reading level will accommodate most? The low-literacy study by Kathryn and Michael Summers is mentioning  because it was based on the usability testing with low-lit users. Kathryn was my faculty and advisor back at University of Baltimore a few year back, and I know that she has done some work with her brother, Michael, who was with Nielsen/Norman Group at the time, on a low literacy project funded by Pfizer. I have learned that existing reading level formulas are tuned to how we naturally speak, which does not apply to technically sophisticated communications. I gather that to know for real, it needs to be tested.
  • A researcher from the University of Twente contacted Boer independently in 2009 to run a study on the font's effectiveness. The small study of 21 dyslexics showed that they made fewer errors when reading text set in Dyslexie compared to "normal" typefaces. Boer set all the text on his website in Dyslexie, and prefers to type in it as well as read. "I hope that I can help people with dyslexia so that the everyday struggle in this information society is a little less," Boer tells Co.Design. "Dyslexie is not a cure, but I see the font as something like a wheelchair." If Dyslexie takes off, perhaps we'll see the rise of whole type studios and foundries dedicated to expanding the graphic options optimized for dyslexic people. After all, why should Dyslexie be the only one?
  • Clayton Lewis, PhD Professor of Computer Science, Scientist in Residence, Coleman Institute for Cognitive Disabilities, University of Colorado
  • The Finnish study is particularly interesting because it was conducted with the youth at a special needs boarding school, which is rare. The study reports that certain usability methods were not ideal for these users. For instance, the think aloud protocol was found unsuitable. As a result, a modified informal walkthrough along with other observational methods were used instead of standard usability testing. The expert evaluation was done at the beginning of the study (as it is typically advised); interestingly enough “the experts were not able to detect problems understanding the ‘big picture’ (general structure) of the [email] application and how moving between the parts of the application could be problematic in this user group.” In discussion, not only the authors stressed the importance of conducting usability studies with people that are cognitively impaired (as opposed to working with proxies such as caregivers, parents, teachers, etc.), but also propose “including a person with cognitive disabilities into the group of evaluators,” which stood out to me.
  • Findings from the literature review and interviews with three experts suggest that the best way to validate how well the design accommodates any breaches in cognitive processing is to test it with users that have cognitive limitations. While there are some tools that can improve the daily experiences of users with cognitive impairments, no automated tool or assistive technology as of now can substitute for user research, design, and testing.
  • And you can help bringing a better cognitive accessibility, so many others will benefit as well.
  • The goal of the GPII project, also referred to as the Cloud Computing Accessibility Initiative, is to allow easy access to assistive technologies anytime and anyplace via user generated profiles. Once a user profile is created, it will store information pertaining to that user in the cloud. Each user can have multiple profiles. In a nutshell, a user profile will specify assistive technologies (such as screen readers), plug-ins (like Browse Aloud that SSA already has available), and other enhancements desired by the user as well as preferences (screen resolution, font, color, etc.). As soon as the user authenticates – whether from a public library, home, or work – the user will access his or her unique profile configuration. Then, the match-maker capability will search for available software services that will be helpful to that user.
  • Video about GPII:
  • Designing for People with Cognitive Disabilities in Language and Literacy

    1. 1. 2
    2. 2. Know Your Users  Graduate student  Online class  Has a disability  Asked more time with his projects  Written work is incoherent  Large fonts 3
    3. 3. The outcome? 4
    4. 4. Designing for People with Cognitive Disabilities in Language and Literacy Yulia Nemchinova, DCD Northrop Grumman and University of Maryland University College UXPA 2013, Washington DC
    5. 5. Expectations  Web Applications  Kiosks  In-person  Phone  Print Publications 6
    6. 6. Who Has Cognitive Disabilities  Seven percent of the population in the US have some type of cognitive, mental or emotional impairment. (Census 2010) 7
    7. 7. Clinical Diagnoses  Attention disorders  Traumatic Brain Injury (TBI)  Developmental disabilities  Cognitive issues related to aging  Learning and language disabilities, including dyslexia 8
    8. 8. Functional Impact  Memory  Attention  Problem solving  Language and reading  Mathematical thinking  Visual and spatial perception 9
    9. 9. Why Are We So Behind? Cognitive impairments are often:  Invisible  Difficult to diagnose  Not universally defined  Not willingly disclosed and  Can be combined with other disabilities 10
    10. 10. 11
    11. 11. A Bit of History  Willowbrook State School 12
    12. 12. When Users Encounter Obstacles…  Lack of confirmation that their action was correct  Cannot find and review features  Cannot recover from errors  Cannot find landmarks  Do not have enough time to complete tasks  Cannot save their work at any time… 13
    13. 13. When Users Encounter Obstacles…  It is a work around for most users  It is a real showstopper for many users with cognitive impairments 14
    14. 14. What can we do? 15
    15. 15. Support Assistive Technologies  Screen readers  Screen magnifiers  Voice recognition  Software for reading & writing help 16
    16. 16. 17
    17. 17. 18
    18. 18. 19
    19. 19. Universal Design 20
    20. 20. Universal Design  Assist most users  One implementation 21
    21. 21. Universal Design: Navigation  Consistent navigation and design  Flat architecture  Functioning Back button  Limited the number of links per page  Standard behavior for links 22
    22. 22. Universal Design: Content for Mobile  Direct access to content  Limited content to process  Availability on any screen size 23
    23. 23. 24
    24. 24. Language & Literacy  Clear and simple text  6-8 reading level  Short pages, paragraphs and sentences  Single column of content  Shorter words are not always better comprehended 25
    25. 25. Dyslexia  26
    26. 26. 27 Targeted Support
    27. 27. Universal Design: Navigation  Consistent navigation and design on every page  Flat navigational architecture  Functioning Back button  Limited the number of links per page  Standard behavior for links 28
    28. 28. Mobile or Slimmed Down Access  Direct access to content  Limited content to process  Availability on multiple electronic devices 29
    29. 29. Finnish Usability Study  An investigation how students with cognitive disabilities use computers  Participants: students with mild intellectual disabilities, limited reading and writing skills  Application: a familiar (used for about 1.5 year) email application  Method: an informal walkthrough with elements of contextual inquiry  Recommendation: inclusion of users with cognitive problems as participants as well as reviewers 30
    30. 30. Usability Testing  Usability studies with cognitively impaired people are extremely rare  User testing is needed  There is no substitution for actual users with disabilities 31
    31. 31. Take Aways  Think universal design  Explore possibilities for user testing  Apply language and literacy guidelines 32
    32. 32. The Future: GPII  Global Public Inclusive Infrastructure (GPII) 33
    33. 33. 34
    34. 34. Thank you! 35
    35. 35. References: 36 Bergel, M., Chadwick-Dias, A., & Tullis, T. (2005). Leveraging Universal Design in a Financial Services Company. Accessibility and Computing, 82. Bodine, C., & Lewis, C. (2004). Rehabilitation Engineering Research Center (RERC) for the Advancement of Cognitive Technologies. Accessibility and Computing, 80. Cole, E. (2011). Lessons Learned and Challenges Discovered in Developing Cognitive Technology for Individuals with Brain Injury. Proceeding of CHI 2011. Czaja, S. J., Gregor, P., & Hanson, V. L. (2009). Introduction to the special issue on aging and information technology. ACM Trans. Access. Comput, 4. Fernando, S., Elliman, T., Money, A., & Lines, L. (2009). Age Related Cognitive Impairments and Diffusion of Assistive Web-Base Technologies. Universal Access in HCI, Part I, HCII 2009 (pp. 353-360). Springer-Verlag Berlin Heidelberg.
    36. 36. References (contd.): 37 Francik, E., Levine, S., Tremain, S., Roberts, E., & Bayha, B. (1999). Telecommunications Problems and Design Strategies for People with Cognitive Disabilities. Annotated Bibliography and Research Recommendations, World Institute on Disability. Gordon, W. A., & Nash, J. (2005). The Interface Between Cognitive Impairments and Access to Information Technology. Gregor, P., & Dickinson, A. (2006). Cognitive difficulties and access to information systems – an interaction design perspective. Hagood, K., Moore, T., Pierre, T., Messamer, P., Ramsberger, G., & Lewis, C. (2010). Naming Practice for People with Aphasia in a Mobile Web Application: Early User Experience. ASSETS: ACM Conference on Assistive Technologies, 273-274. Hanson, V. L. (2009). Cognition, Age, and Web Browsing. Universal Access in HCI, Part I, HCII 2009, (pp. 245-250). Springer-Verlag Berlin Heidelberg.
    37. 37. References (contd.): 38 Jansche, M., Feng, L., & Huenerfauth, M. (2010). Reading Difficulty in Adults with Intellectual Disabilities: Analysis with a Hierarchical Latent Trait Model. ASSETS’10,. Orlando, Florida, USA. Judson, A., & Nicolle, C. (2004). Internet accessibility for people who use augmentative and alternative communication. Conference Proceedings -- International Society for Augmentative & Alternative Communication, 181-186. Keates, S., Kozloski, J., & Varker, P. (2009). Cognitive Impairments, HCI and Daily Living. Universal Access in HCI, Part I, HCII 2009 (pp. 366-374). Springer-Verlag Berlin Heidelberg. Lepistö, A., & Ovaska, S. (2004). Usability evaluation involving participants with cognitive disabilities. NordiCHI '04. Tampere, Finland. Lewis, C. Cognitive and Learning Impairments. Lewis, C. (2008). Cognitive Disabilities. In The Universal Access Handbook.
    38. 38. References (contd.): 39 Lewis, C. (2006, May-June). HCI and Cognitive Disabilities. Interactions , pp. 14-15. Lewis, C. HCI for People with Cognitive Disabilities. Lewis, C. (2006). Simplicity in cognitive assistive technology: a framework and agenda for research. Univ Access Inf Soc (pp. 351-361). Springer-Verlag. Moffatt, K., & Davies, R. (2004). The Aphasia Project: Designing technology for and with individuals who have aphasia. Accessibility and Computing, 80, pp. 11-17. Poncelas, A., & Murphy, G. (2007). Accessible Information for People with Intellectual Disabilities: Do Symbols Really Help? Journal of Applied Research in Intellectual Disabilities. 20, pp. 466-474. BILD Publications. Poulson, D., & Nicolle, C. (2004). Making the Internet accessible for people with cognitive and communication Impairments. Universal Access in the Information Society, 3(1), 48-56.
    39. 39. References (contd.): 40 Redish, J. (., & Chisnell, D. (2004). Designing Web Sites for Older Adults: A Review of Recent Literature. AARP. Rowland, C. (2010). Accessibility: The Need for Champions and Awareness in Higher Education. Educause Review, 45(6), 12. Rowland, C. (2010). Transforming the Institution. Educause Review, 45(6), 14. Savidis, A., & Stephanidis, C. (2004). Developing Inclusive e-Learning and e- Entertainment to Effectively Accommodate Learning Difficulties., (pp. 42-54). Solheim, I. (2009). Adaptive User Interfaces: Benefit or Impediment for Lower- Literacy Users? Universal Access in HCI, Part II, HCII 2009 (pp. 758-765). Springer-Verlag Berlin Heidelberg. Summers, K., & Summers, M. (2005). Reading and Navigational Strategies of Web Users with Lower Literacy Skills. Proceedings of the American Society for Information Science and Technology, 42.
    40. 40. References (contd.): 41 Vigouroux, N., Rumeau, P., Vella, F., & Vellas, B. (2009). Studying Point-Select- Drag Interaction Techniques for Older People with Cognitive Impairment. Universal Access in HCI, Part I, HCII 2009 (pp. 422-428). Springer-Verlag Berlin Heidelberg. Walser, K., Quesenbery, W., & Swierenga, S. (2008). Designing for Cognitive Disabilities. UPA 2008 – The Many Faces of User Experience. Baltimore, Maryland, USA. WebAIM. (n.d.). Cognitive and Learning Disabilities Literature Review. Retrieved from WebAIM Web Accessibility in Mind: WebAIM. (n.d.). Steppingstones Project on Web Accessibility and Cognitive Disabilities in Education. Retrieved from WebAIM Web Accessibility in Mind: