Using a Handheld Computer as a Cognitive-Behavioral Tool Tony Gentry, PhD OTR/L Virginia C om m onw ealth U niversity Assistive Technology for Cognition L aboratory D epartm ent of Occupational T herapy Apple's ipod touch and ipad, and the grow ing catalog of A ndroid and M icrosoft tablets, are rem arkably versatile and agile tools th a t have tak en the consum er w orld by storm . W ithin the disability com m unity, it has becom e clear th a t th ese devices can b e readily custom ized and ad ap ted to ad d re ss cognitive-behavioral challenges. Because th e y are so portable, th e y can be used as behavioral supports a t home, at school, at w o rk and in th e community. Because th e se devices can do so m uch, it can be challenging to figure out w hat to do first. The following guidelines are based on a decade of com m unity-based PDA research in VCU's Assistive Technology for Cognition laboratory. They are no t intended as s tric t rules, but as suggestions for w ays to get th e m ost from th ese products.

R em em bering to Do Things The very first Palm Pilot PDAs came w ith to do list apps and calendars w ith rem in d er alarm s, giving them a distinct advantage over paper-based scheduling p roducts. Setting an alarm for daily tasks can b e a gam e-changer for people w ith m em ory or a tte n tio n challenges, and c u rre n t devices offer a w ide range of tools for doing ju st that. Apple products include a Calendar th a t allow s alarm s to be tagged to everyday events; the iphone and ipod touch also offer a versatile Clock app th a t allow s y ou to choose a custom ized rem in d er sound for each ta s k (including one particularly in sisten t rem in d e r th a t only tu rn s off w hen you tap the screen). A ndroid tablets include Google Calendar, and M icrosoft tablets include a tab le t version of Outlook, b o th of which in co rp o rate rem in d er alarm s. All of these products feature note-taking apps th a t allow for the creation of to do lists. T here are at least 500 add-on apps available, offering v a ria n ts on these onboard calendars. For Apple products, the online iTunes Store is w h ere you will find them . For A ndroid products, search th e online A ndroid Market.

Task-Sequencing & Wayfinding People w ho have difficulty learning to com plete m ulti-step task s independently (m orning groom ing tasks, com plex job skills, etc.) can use th ese devices as ta s k coaches. Some people only need a step-by-step w ritte n ta s k list, or a list th a t includes a p ictu re prom pt. Errands, Visules and H om eRoutine are inexpensive apps for creating such supportive ta s k sequences. You can also create a P ow erpoint sequence of pictures and captions for any task, click to create a m ovie version and dow nload th a t for playback on your handheld device. For p eople who need audiovisual support, you can create a video show ing th e ta s k being perfo rm ed successfully, and have it available for playback w h en needed. Most c u rren t PDAs and tab le ts come w ith onboard video recording capabilities. Using th ese videocam eras, it is easy to bu ild videos show ing tu rn -b y -tu rn ro u te s th ro u g h a building o r across a campus. For m any people w ith cognitive challenges, th ese videos are e asier to follow th a n the abstracted im ages on m aps.

Social Stories and Behavioral Cues As w ith task-sequencing, supports m ay include a w ritte n set of directions, a captioned p ictu re sequence, or a videotape m odeling a p p ro p ria te behaviors. See the attached Video Modeling using Handheld Computers for m ore inform ation about th is approach.

Stress M anagem ent Relaxation apps, a rt and m usic apps an d m any puzzle and game apps can help people relax in stressful situations. SimplyBeing, for instance, plays new age m usic and show s relaxing n a tu ra l scenes, w hile Tactical Breathing Trainer and Breathe2Relax use sim ple video graphics to teach deep b re a th in g relaxation m ethods. Bloom and Seline HD are entrancing music apps, WURM and M eritum P a in t are relaxing finger painting apps, and th e re are tho u san d s of puzzle and gam e apps th a t m ay appeal.

Academ ics, Healthy Living and Beyond You m ay w ish to use your portable co m p u ter as a hom ew ork tracker. iHomework and iStudiez Pro provide com prehensive su p p o rt for classw ork, planning and rem inders. Dictionaries, algebra helpers, astro n o m y m aps and frog dissection sim ulations are ju st a few of the tho u san d s of academ ic ap p s now available. You m ay also use y o u r handheld device as a health coach. All Fitness, for instance, provides video-guided w orkouts, Sleep Cycle p u rp o rts to tra c k your sleep habits, and Lose it! is one of m any calorie counting w eight loss apps on the m arket. Clearly, it is possible to build a p ersonalized suite of supportive apps on your sm artphone, ipod touch, ipad o r tablet. I w ish you luck as you do so, and w ould like to hear about your experiences. Please c o n ta c t me at logentry@ vcu.edu.

Video Modeling u sing iPod Touch, iPad or other Tablets Tony Gentry, PhD OTR/L Virginia C om m onw ealth University D epartm ent of O ccupational Therapy Assistive Technology for Cognition Laboratory Of all th e assistive technologies used to su p p o rt people w ith cognitive-behavioral challenges, the m ost thoro u g h ly researched is video modeling. M ore th a n 60 studies have b e e n published in the p a st 20 years, show ing th a t m any p eo p le w ith cognitive difficulties can learn to perform complex task s and m anage social behaviors w h en a vid eo tap ed rep re sen ta tio n of th e activity is u sed for guidance. W ith the rec e n t em ergence of videocam era-equipped sm artphones, ipod touches and com puter tablets, op p o rtu n ities to utilize video m odeling strategies have grown. These devices typically offer sim ple one-touch video recording and playback, and som e include editing softw are th a t allow s for clip trim m ing, titles and so undtracks. For the fir s t time, we now have truly portable tools fo r creating, editing and using video as a behavioral aid. O pportunities to utilize video m odeling include: (1} task-sequencing of com plex everyday tasks (groom ing, packing a backback, etc.); (2) w ayfinding guidance (though m any portable devices now have GPS m apping, m any people w ith cognitive-behavioral challenges find tran sferrin g w h a t they see on a m ap to w h a t they see in th e real w o rld difficult - a video th a t show s exactly w h e re they are, w hich doors to use, which tu rn s to m ake, etc., can be m ore successful as a w ayfinding guide); (3) v id eo tap ed social stories for m anaging difficult situations; (4) behavioral advice and guidance; and (5) gen eral encouragem ent from a loved one. Apple h as recen tly m ade available on th e ir App Store a sim plified version of th e ir iMovie film p ro d u ctio n softw are, w hich allows cu t-and-paste and oth er editing tasks to be perform ed directly on an iphone, ipod touch or ipad. A ndroid devices will soon have a sim ilar editing product. In m any cases, how ever, if you follow the guidelines listed below, you will not have to edit th e video at all.

Making Behavioral Guidance Videos In building a p erso n al library of video m odeling su p p o rts on a perso n 's handheld device, it is im p o rta n t to pay a tten tio n to basic p ro d u ctio n values: 1)

2) 3) 4)

5)

B revity: Videos should be s h o rt and a d d re ss ju st one behavior. Strive for one m inute or less, w h en possible. It is e asier for a u se r to ta p on a new task video th an it is to scroll th ro u g h a longer video for th e next cue. C lose-ups: Rem em ber th a t th e device playing back th e video m ay be palm -sized, so it is a good idea to use close-ups. Lighting: Make sure th a t good lighting is available. Steady h a n d s: W hen possible, prop th e video recording device on a table o r at least try to hold it as stead y as you can w hile recording; no one likes to w atch a video th a t seem s to have b e e n sh o t on a boat in a pitching sea. Audio P ro m p ts: Record v erbal step-by-step task or directional cues w hile shooting the video, since adding in a so u n d track la te r can be tim e-consum ing.

6} 7)

Titling: Be sure to give the video an ap p ro p riate title, such as "make lunch", so th e u se r can readily scroll to it on the device w h e n needed. P a rtn e rin g : It's usually a good idea to collaborate w ith the end u se r in m aking the video. See if h e /s h e can act in the video or help w ith shooting or editing. This can im prove user buy-in for independently accessing the video w hen needed.

Training and Follow-Along In beginning to use a behavioral guidance video, a u se r m ay w ish to: [1) w atch th e video all the w ay through ju s t before attem pting a chosen activity, [2) have th e video onscreen for play-and-pause guidance during th e activity, and [3) w atch th e video again all the w ay th ro u g h at com pletion of the activity in o rd e r to com pare the video to h e r/h is actual perform ance. This strateg y helps build com petence and insight through repetition and practice. In m any cases, users eventually w ean them selves off of needing th e video pro m p t a t all. M any feel reassured, how ever, th a t they have a readily available guide on th eir device w henever it m ay be needed. This strateg y h as been show n successful w ith p reschoolers, students and adults on job sites, and com parison studies have show n it to b e m o re successful th an o th er form s of p ictu re prom pting o r behavioral reh earsal techniques. A behavioral guidance video will only be successful if the u ser w atches it and trie s to follow th e v ideotaped m odel. As noted, u ser p articipation in choosing w h a t videos to m ake a n d in m aking the video can help w ith buy-in. Som etim es a rew a rd system can help users get s ta rte d in m aking use of th e videos. W hen people see th a t using a behavioral guidance video red u ces familial nagging, w hile increasing functional in d ependence and control over behaviors, th e y often begin to use the videos spontaneously, and m ay th e n think of new videos to help them achieve m ore selfefficacy.

Premade Social Story Videos If you do n o t feel com fortable m aking y o u r ow n videos or w ould like to explore professional m ade versions on your portable device, you can do so. T here are a n u m b er of video p rom pting apps available. Two good ones are: (1) Going Places, a free app th at includes 6 com m unity activity videos w ith captions [getting a haircut, for instance) and [2) Everyday Skills, a $40 app that includes a library of 40 behavioral videos for children and adults. I w ish you luck in y o u r film -m aking c a re e r and look forw ard to h earin g about y o u r efforts in using handheld com puters to live fuller, m o re in d ep e n d e n t lives. Please contact me at logentry@ vcu.edu.

Functional A ssessm en t Tool for Cognitive Assistive Technology (FATCAT) Client:___________________________________

Identifying No..

A ssessm ent Date:_____________________________________ Functional Cognition: P le a s e ask client to rate how well th e following task s a re performed, on a 1 to 10 scale, with 1 being very p o o r a n d 10 being excellent. Hom e an d C om m unity Tasks

H om e safety Way-finding in the community Performing routine activities Keeping track of appointm ents Taking m edications on sc h e d u le Performing multi-step ta s k s (cooking, shopping, etc.) Multi-tasking (doing two or m ore things at the s a m e time) Following through on plans R em em bering important ev e n ts R em em bering everyday e v e n ts Managing frustration Staying focused on a project R em em bering facts (n am e s, p a s sw o rd s , p h o n e num bers) Keeping track of keys, wallet, o ther items Learning n e w information Dealing with Distractions Total score: Divide sc o re by 16 for self-rating:

Perform ance

1 1 1 1 1 1

2 2 2 2 2 2

3 3 3 3 3 3

4 4 4 4 4 4

5 5 5 5 5 5

6 6 6 6 6 6

7 7 7 7 7 7

8 8 8 8 8 8

9 9 9 9 9 9

10 10 10 10 10 10

1 2 3 4 5 6 7 8 9 10 1 1 1 1

2 2 2 2

3 3 3 3

4 4 4 4

5 5 5 5

6 6 6 6

7 7 7 7

8 8 8 8

9 9 9 9

10 10 10 10

1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10

Access to Device: Yes

No

Client d e m o n s tra te s : Ability to read information on PDA Ability to h e a r PDA alarm w hen 5-feet aw ay Sufficient dexterity to navigate PDA interface R esponds to alarm rem inder and perform s ta s k as reminded

© Tony Gentry 2010

Current Use of Technology: Check w hether client is proficient (P), a novice (N) or d o e s n 't use (NA) technology. N

p

NA Technology PDA (device type: ) Cellphone Cellphone ta s k m a n a g e m e n t functions Personal c o m p u te r word processing Personal c o m p u te r email Personal c o m p u te r w eb surfing Personal c o m p u te r advanced (sp re a d sh e e ts, m oney m a n a g e m e n t) Gaming sy ste m s: Wii, PS3, X-Box (circle which) Handheld gam ing device (Nintendo DS, etc.) Portable music player (ipod, etc.) TV R em ote control

N eeds and P references (Basic Functions): Check Function

Check

Reminder alarm Calendar Activity Schedule To Do list Addresses, p h o n e num bers Arm-strap Belt-clip

Function

Calculator Electronic sticky note G am es Photo Album Store passw ords Pocket-sized Around-the-neck lanyard

N eeds and P references (Advanced Functions): Check Function

T ask-seguencing cues* Voice m e m o s Keyboard Wireless capability Behavioral coaching* Voice-over *

Check

Function

Video playback Cam era GPS navigation Vibrating alarm Directional m aps Magnification

If c h e c k e d , d e te r m in e m o d ality o f c u e s n e e d e d (te x t, g ra p h ic s, v id e o , etc .)

O th e r Needs and P references:

© Tony Gentry 2010

Device Provided:

Case/accessories:

Applications:

Training strategy:

Follow-up:

Trouble-shooting:

© Tony Gentry 2010

A ddendum (vocational tasks): Vocational Tasks

Getting ready for work Getting to/from work T y p e of transport: Clock in/clock out M anaging weekly work sc h ed u le /c a le n d a r W ork Tasks:

M anaging breaks a n d b reak times Co-w orker relationships C u s to m e r relationships Following through on plans Dealing with a c h a n g e in routine Asking for help, w hen n e e d e d M anaging frustration Staying focused on a project Learning new task s Dealing with Distractions Total score: Divide by num ber of items for self-rating:

© Tony Gentry 2010

P erform ance

1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 1 1 1 1 1

2 2 2 2 2

3 3 3 3 3

4 4 4 4 4

5 5 5 5 5

6 6 6 6 6

7 7 7 7 7

8 8 8 8 8

9 9 9 9 9

10 10 10 10 10

1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5

6 6 6 6 6 6 6 6 6 6

7 7 7 7 7 7 7 7 7 7

8 8 8 8 8 8 8 8 8 8

9 9 9 9 9 9 9 9 9 9

10 10 10 10 10 10 10 10 10 10

A pps R esource G uide

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Gentry-VCU-2013

Behavioral management reward system. Fill in a puzzle and when complete win virtual reward. Designed by VA, tool allows self-assessment, symptom tracking, provides health tips and links to providers. Designed by VA, track anxiety, depression, head injury, PTSD, stress symptoms on graph and share with care providers. Track mood, w ork through issues w ith question-prompt virtual therapist. Offers CBT-based recommendations for symptoms o f OCD, depression, anxiety and eating disorder (different app for each condition). D ata collection tool for counting behavior by simple tallies or percentages, recording session duration, and emailing the data Tracks ABC data, frequency and duration, and high frequency data Graphs all o f the data (by frequency, duration, or rate) T ask-Sequencing Onboard iOS app, take text-based notes. Audio based to do lists. Can create list within list. Task organizer- attach photo, video, or audio to rem inder message Ability to sort tasks into categories Aids in recall o f details- record notes (audio or video) to accompany a photo in a listed schedule D irectly links a rem inder message to a prompting video! Audio-visual prom pting tool for scheduling daily events or steps to complete an activity Visual schedules provide positive behavioral supports Completely customizable (e.g. record their own voice, add their own images) Onscreen corkboard allows picture and sticky note daily prompts; create different boards for different tasks. Fully-featured pro version is $4.99 Create to do lists within to do lists, and append picture to them for non-readers. Check o ff work when done. A nd you can set reminder alarms for your lists! Create talking picture books directly on your device; task-sequencing/wayfinding, social stories, etc. Create picture-audio-text slide shows for step-by-step instruction Create and upload instructional task sequences, ju st like Powerpoints, with pix and text, to SnapGuide website. Explore website and watch those others have posted. Create check-off task lists, can add photos for non-readers. D esigned for busy homemakers, allows check-off task lists, lists within lists. Set goals and win virtual rewards, share successes w ith friends on Facebook.

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Virtual school notebook, tracks classes and assignments, automatically links to iCal Calendar. Reminders. - Allows one to keep track o f their homework, classes, projects and tests - Design o f application resembles day to day notebook separated by colorful sticky pads that mark the pages - Notifies you w hen you have upcoming assignments by numbering them on your application icon Can transfer hom ework or class entries to friends and email work reminders - A nother virtual school notebook, not as fully-featured, but FREE - N ote-taking app allows you to append pix, draw, and save notes to Evemote. - N ote taking application and to-do manager - Able to customize with themes with different folder icons, colors, fonts, and paper backgrounds - Can send notes with photo attachments as emails, Post-it styled notes, as well as synchronization w ith Google Docs and Evemote - Create text, photo and audio notes that synchronize with your computer - Add, sync, access, and share files (PDF, Word, Excel, PowerPoint, etc) - Audio record a lecture, type as you attend, and at home tap your note to hear ju st w hat the teacher was saying at that time. Saves time in notes review. - Like Notability, and you can draw with a finger or use keyboard. V isual - W ith large, high-contrast text, it’s easier to select and call a person from your contact list Supports both portrait and landscape orientation - Has English, German, Japanese and French language support - Application translates English to Braille and vice-versa Ideal application for individuals who are farsighted, those who have reading glasses, bifocals, or for anyone w ho needs to see more clearly - Uses your device camera to clearly display text or imagery - Can choose betw een 2x, 4x, 6x or 8x magnification and hold iPad (as well as iPod touch or iPhone) about 5 inches away from object that needs to be magnified - Uses device cam era to read and speak denomination o f paper money. - Links VoiceOver setting to Google M ap to give you verbal tum -by-tum directions when walking. ___ : __Set up news, weather, email, other content feeds and Voice B rief will read them aloud to you.

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U ses device cam era to identify and speak names o f objects, items, store goods, paper money denominations, etc. You will need wi-fi or cellular connection, as it works over Internet. A n auditory timekeeper, chimes on hour or other time setting. Free; add additional chime sounds for money. H earin g Dial phone numbers w ithout looking at the keypad M ove fingers over keypad to hear phone number digits, then select digit by releasing Able to choose between tw o voices (Alex and Jules) Can dial last 6 previous numbers (history) M agnifies sound and plays it through earbuds - a poor m an’s hearing aid. N avigation GPS tracker w ith mapping- allows you to track a cellphone route and send your location to another phone or PC Navigation system for driving or walking (mobile phone navigation) Has a tracking and tracing feature available (allows viewing o f vehicle movements) W orks best w ith phone plan - register and allow others to track your location Comes w ith iOS 6, use A pple ID and track Contacts who log on. A local yellow pages with local map, w herever you are. Siri and Dragon Go do this too, o f course. W ith wi-fi, you can speak a request to this app, and it will search your device and the web for an answer (weather, local coffee shop, etc.) Like Siri, but doesn’t talk back to you. Often works when Siri w ill not. R em inders These rem inder apps come with iOS 6. Clock not on iPad. Spoken word rem inder app for non-readers or those with visual impairment Another spoken word rem inder app, this one free (with ads) or $1.99 without ads Easy to use rem inder app that allows others to send you reminders and track your activities. You can share to do lists, etc. Electronic sticky note with rem inder alarm. You can append a picture, draw on it, etc. Works well for non-readers who need a picture prompt. Easy to use audio recording app. For to do lists, etc. Can be used as an augmentative communication tool, if you make a library o f phrases to play back. Easy to use rem inder app, w ith different sounds, timers. A n alternative to Clock for iPad and Android.

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Gentry-VCU-2013