Page 45 - Handbook of Electronic Assistive Technology

32 HANDBOOK OF ELECTRONIC ASSISTIVE TECHNOLOGY

One difficulty – linked to a lack of awareness – that is often described by neuropsycholo-
gists working with those with cognitive impairments, is ‘concreteness’. People exhibiting
concreteness may be oriented toward the present environment and unable to reflect on their
own behaviour, or think symbolically or in abstract terms (Salas et al., 2013). Concreteness
is not to be thought of as an impairment to specific cognitive abilities, instead patients that
are concrete in their thinking experience the world in a different way to those who can ori-
ent their actions from a conceptual point of view. It could be challenging to introduce EAT
for patients exhibiting concreteness, especially if the technology requires lengthy training,
at moments when the patient is not experiencing the difficulty that the technology is there
to support. For example, if a patient has difficulty with memory and is being taught how to
use a reminding technology, or even a pencil and paper diary, they may not see the purpose,
because they say their memory is fine, perhaps citing upcoming events that they remember.
For patients presenting in this way, it may be necessary to be creative in the way that EAT
is introduced, and to use techniques that help people become aware of their need for an
intervention beyond the immediate moments when they have difficulties (Salas et al., 2013).

Motivation
Motivation is one aspect of intentional behaviour. It involves the ability to initiate activity
and, alongside self-awareness, it is another important factor associated with outcomes
of rehabilitation and technology use (O’Neill and Gillespie, 2017; Wood and Worthington,
2001). Those with motivational deficits may present with difficulties in thinking of
things to do or in initiating activities, even when they are able to carry out quite com-
plex activities. Some respond well to environmental cues, they will eat or drink what is
put in front of them, but others will need explicit instructions or prompts (Lezak et al.,
2004). Understanding the nature of motivation disorders will give an indication of how
likely a person is to respond to therapeutic interventions or benefit from different types of
technology. Oddy, Worthington and Francis’ (2009) framework for motivational disorders
considers the role of arousal and fatigue levels, and six stages of goal-directed activity:
(1) idea generation, (2) selection, (3) formulation of a plan, (4) initiation, (5) monitoring
and (6) review and reinforcement. When used to guide assessment and formulation, the
model can help select the most appropriate interventions, but it may also help a person
and their family to understand the nature of their difficulties and avoid the frustration
that commonly occurs in the context of these deficits (Oddy et al., 2009). This framework
is transferable to the context of an assistive technology assessment, as technology can be
employed or designed in such a way that supports and promotes its use. For example,
automated verbal instructions can be provided by a device to reduce the detrimental effect
that being unable to recall operation instructions may have on initiating use (Cullen et al.,
2008). Microprompting software can be embedded to support users to correctly set up
and benefit from devices safely (O’Neill et al., 2010). Environmental or wearable technol-
ogy can make integrated devices aware of the context that surrounds them (O’Neill and
Gillespie, 2017), and automatically deliver the required support, prompt or encourage
users to engage with the device (Oddy and Ramos, 2013; Ramos et al., 2014).