Gap Analysis/autism

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Description

"Autism spectrum disorder (ASD) is a developmental disability that can cause significant social, communication and behavioral challenges. There is often nothing about how people with ASD look that sets them apart from other people, but people with ASD may communicate, interact, behave, and learn in ways that are different from most other people. The learning, thinking, and problem-solving abilities of people with ASD can range from gifted to severely challenged. Some people with ASD need a lot of help in their daily lives; others need less.

A diagnosis of ASD now includes several conditions that used to be diagnosed separately: autistic disorder, pervasive developmental disorder not otherwise specified (PDD-NOS), and Asperger syndrome. These conditions are now all called autism spectrum disorder." (See 2.)

Cognitive functions

1. "Memory
2. Problem-solving
3. Attention
4. Reading, linguistic, and verbal comprehension
5. Math comprehension
6. Visual comprehension" (See 5.)

Symptoms

"People with ASD often have problems with social, emotional, and communication skills. They might repeat certain behaviors and might not want change in their daily activities. Many people with ASD also have different ways of learning, paying attention, or reacting to things. Signs of ASD begin during early childhood and typically last throughout a person’s life.

Children or adults with ASD might:

• not point at objects to show interest (for example, not point at an airplane flying over)
• not look at objects when another person points at them
• have trouble relating to others or not have an interest in other people at all
• avoid eye contact and want to be alone
• have trouble understanding other people’s feelings or talking about their own feelings
• prefer not to be held or cuddled, or might cuddle only when they want to
• appear to be unaware when people talk to them, but respond to other sounds
• be very interested in people, but not know how to talk, play, or relate to them
• repeat or echo words or phrases said to them, or repeat words or phrases in place of normal language
• have trouble expressing their needs using typical words or motions
• not play 'pretend' games (for example, not pretend to 'feed' a doll)
• repeat actions over and over again
• have trouble adapting when a routine changes
• have unusual reactions to the way things smell, taste, look, feel, or sound
• lose skills they once had (for example, stop saying words they were using)" (See 2.)

Different list of symptoms:

• poor social skills
• difficulty with change and transition
• impairments in executive function

• "manage time and attention
• switch focus
• plan and organize
• remember details
• curb inappropriate speech or behavior
• integrate past experience with present action" (See 6.)

• sensory integration

• sensitivity to physical contact
• sensitivity to loud noises

• stereotypy

Their challenges

How Symptoms Result in Challenges for This Group

• may not pay attention to primary content because distracted by secondary content
• may be confused by:

• instructions that are not well-defined
• transitions among content-delivery types (e.g., text to video)
• presentations of content using different formats or designs

• may not participate in web-based interactions with other people
• may not recall instructions when subsequently presented with an action to perform
• may react negatively to auto-playing video or audio

Observations from Interview with Anonymous User X

• Positive: web facilitates social communication between those who struggle with face to face communication.
• Negative: communication via the web allows people with ASD to become even more isolated.
• Often the web is avoided except for work or communication purposes as it is not very user friendly.
• Some websites specifically are avoided due to the predominant color (red is particularly bad).
• In many cases there are some very-useful accessibility features that users of websites and applications have the option to adjust. However, it is often difficult to find out how and where to do this. (See 10.)

Suggestions from Interview with Anonymous User X

• It is easier to view websites that are more visual and use only plain, simple language that doesn’t contain any jargon.
• Numerous search results can be difficult to sort through to find the right link. Therefore, easy-to-access links are more helpful without many options.
• Font: very much a personal preference, however in general:

• Big, plain fonts at least point 12.
• Bold fonts not skinny.
• Sites that allow users to customize the font to their own preferences.

• Color coordination for different parts of the site relating to each other.
• Key for different colors for different sections.
• In some cases poor concept of time means can be looking at one site/page/document for many hours without realizing - timer on screen to alert user to how long they have been on that page. (See 10.)

Some persona with use cases that address key challenges

Scenario A: Use a Web Browser to Open a Web Page

"Trevor is a bright 18-year-old who plays games and watches music videos on his laptop. He lives at home with his parents and younger sister. He attends a special school where the teachers and staff can help with his social and communication challenges from his Autism Spectrum Disorder, while he works to pass his high school exams.

He has problems with visual information and recognizing things on the page, and his reading skills are not helped by his trouble concentrating on the page or screen long enough to read. His teachers showed him how to make the text bigger on the page, and told him how to use a printable view to hide all the ads with moving images that distract him, because he reads every word on the page very carefully and literally. He can be easily confused by colloquialisms and metaphors. He can also be overwhelmed by sites that offer too many choices.

He likes using the school’s forum to talk to his friends. It’s easier to just read what they want to say than to listen and try to figure out their facial expressions.

He shares a laptop with the family, but has first dibs on it because his parents want him to get his schoolwork done. He uses it for homework, but he really likes games with repetitive actions. He doesn’t like new sites much, in the same way that he doesn’t like any changes in his routine: they are tolerated, but not encouraged." (See 8, 9.)

Step	Challenge	Solutions	Comments
1. Activate / open the web browser.	Remember how to start the web browser.
2. Open the website.	Recall the web address and know how to invoke it with the web browser.	Enter the web address.
3. Navigate the website.	Familiarize / recall how to use it; and understand icons/text labels and navigation menus.
4. View a webpage.	Comprehend the content without being distracted by advertisements, extraneous content, etc..	Increase font size and/or activate the print view of the web browser.	The solutions may be mutually exclusive.

Scenario B: Send an Email Message

Middle-aged female with PDD-NOS (Pervasive Development Disorder-Not Otherwise Specified). She experiences significant social deficits and meets all the diagnostic criteria for autistic disorder, but her stereotypical and repetitive behaviors are noticeably mild. She finds it easier to send an email message than communicate via speech with people as it eliminates any social anxiety she may experience when interacting with people in person.

Step	Challenge	Solutions	Comments
1. Turn on computer.
2. Launch email application.	The first issue here arises from the glaring white background that is often used in email applications along with poorly-contrasted small fonts. Although there are options for changing some of the design settings, these are often hard to find and difficult to navigate.
3. Select button to compose new email message.	Users with autism have a tendency to take a literal understanding of what people say and write. Therefore, the users may not understand any connotations, and are also prone to perhaps lack emotion in their own writing. There is a potential issue here as what users write may come across as unnecessarily blunt even though this is unintended. Similarly, users may misinterpret what is written to them by not understanding the connotations. When reading emails, users with ASD will often break down lengthy emails into more manageable chunks and edit the style/size/color of font.
4. Type in address of recipient.	Facilitate comprehension and minimize distractions.	Increase font size and/or activate the print view of the web browser.
5. Send email message.

Scenario C: Buy a Train Ticket Online

Older male with Asperger’s who does not have any cognitive impairment. However, he exhibits repetitive behavior and has significant trouble with social situations, specifically communicating with others. He prefers to buy his train tickets online as it eliminates any social interaction which he is not keen on. He struggles to communicate with others successfully. He has extreme anxiety. He has been either unable to purchase a ticket in person, or ended up with the wrong ticket through his lack of ability to express what he needs specifically to the ticket-office attendant. When buying train tickets, there is noticeable task avoidance amongst many people on the spectrum.

Step	Challenge	Solutions	Comments
1. Turn on computer.
2. Open web browser.
3. Type in web address for train ticket booking website.
4. Select icon for booking train tickets.
5. Tick box for ‘return’.
6. Type in departure and arrival locations.
7. Select date and time for outbound and return journeys.
8. Select number of adult and child passengers.
9. Tick box for railcards.
10. Select railcard type and number that apply for this journey.
11. Select continue.
12. Tick box to select specific outward & return journeys (details to look at: time, price, class and single/return).	May have a poor concept of time, meaning it is difficult to calculate if a train will arrive in time, especially where the journey involves changing trains.
13. Select ‘buy now’.
14. Tick box to reserve seat and if so select seating preferences- optional.
15. Tick box to either: collect tickets from self-service ticket machine and select station; or have tickets sent by post.
16. Select ‘continue’.
17. Tick box 'new user'.
18. Type in personal details (Name, Address, Email, etc.).
19. Tick box payment card type (Visa, MasterCard, etc.).
20. Enter card details (number, expiry date, name, security code).
21. Type in home address.
22. Tick box to agree to terms and conditions and select ‘buy now’.
23. Enter payment-card secure-bank password.
24. Click 'Submit' button.

Scenario D: Shop an Online Supermarket

Young adult male with ‘classic’ Autism. He has a severe cognitive delay and is non-verbal, a side effect of which is extreme social inhibition. He is able to communicate via pictures when necessary with his family and carers. A local supermarket is a good example of a place where he can easily become overwhelmed, which severely affects his ability to communicate effectively. However, in the comfort of his own home he is much better able to function, and therefore is less dependent upon others for help. The task of online shopping is made much easier if a very- specific item is required and there is little choice.

Step	Challenge	Solutions	Comments
1. Turn on computer.
2. Open web browser.
3. Type in web address for online supermarket website.
4. Select ‘food and drink’ and then ‘buy groceries’.	Entering a search item may produce many results. This can be confusing if they are all similar, as it can be difficult to choose which one is best.	Increase font size and/or activate the print view of the web browser.
5. Select groceries to purchase.	Most items available for purchase will have an image alongside their descriptive text. This should help when choosing the correct items. However, there is a level of inconsistency across different online supermarket shops regarding the images they use to denote each their products. This can be very confusing.
6. Select ‘buy now’.
7. Log in with username and password.
8. Select delivery date and time.
9. Type in delivery-address details.
10. Select payment method.
11. Type in payment-card details.
12. Select ‘order’.

Characteristics of content optimized for this group

Consistency

• "Ensure that navigation is consistent throughout a site.
• Similar interface elements and similar interactions should produce predictably similar results." (See 7.)

Transformability

• "Support increased text sizes
• Ensure images are readable and comprehensible when enlarged
• Ensure color alone is not used to convey content
• Support the disabling of images and/or styles" (See 7.)

Multi-modality

• "Provide content in multiple mediums
• Use contextually-relevant images to enhance content
• Pair icons or graphics with text to provide contextual cues and help with content comprehension" (See 7.)

Focus and Structure

• "Use white space and visual design elements to focus user attention
• Avoid distractions
• Use stylistic differences to highlight important content, but do so conservatively
• Organize content into well-defined groups or chunks, using headings, lists, and other visual mechanisms
• Use white space for separation
• Avoid background sounds" (See 7.)

Readability and Language

• "Use language that is as simple as is appropriate for the content
• Avoid tangential, extraneous, or non-relevant information
• Use correct grammar and spelling
• Use a spell-checker. Write clearly and simply.
• Maintain a reading level that is adequate for the audience
• Be careful with colloquialisms, non-literal text, and jargon
• Expand abbreviations and acronyms
• Provide summaries, introductions, or a table of contents for complex or lengthy content
• Be succinct
• Ensure text readability

• Line height

The amount of space between lines should generally be no less than half the character height.

• Line length

Very long lines of text (more than around 80 characters per line) are more difficult to read.

• Letter spacing, word spacing, and justification

Provide appropriate (but not too much) letter and word spacing. Avoid full justified text as it results in variable spacing between words and can result in distracting "rivers of white" - patterns of white spaces that flow downward through body text.

• Sans-serif fonts: These fonts are generally regarded to be more appealing for body text.
• Adequate text size (Very small text)

Text should generally be at least 10 pixels in size.

• Content appropriate fonts

Visually appealing and content-appropriate fonts affect satisfaction, readability, and comprehension.

• Paragraph length

Keep paragraph length short.

• Adequate color contrast

Ensure text is easily discerned against the background and that links can be easily differentiated from surrounding text.

• No horizontal scrolling

Avoid horizontal scrolling when the text size is increased 200-300%" (See 7.)

Orientation and Error Prevention/Recovery

• "Give users control over time sensitive content changes

Avoid automatic refreshes or redirects. Allow users to control content updates or changes. Avoid unnecessary time-outs or expirations. Allow users to request more time.

• Provide adequate instructions and cues for forms

Ensure required elements and formatting requirements are identified. Provide associated and descriptive form labels and fieldsets/legends.

• Give users clear and accessible form error messages and provide mechanisms for resolving form errors and resubmitting the form
• Give feedback on a user's actions

Confirm correct choices and alert users to errors or possible errors.

• Provide instructions for unfamiliar or complex interfaces
• Use breadcrumbs, indicators, or cues to indicate location or progress

Allow users to quickly determine where they are at in the structure of a web site (e.g., a currently active "tab" or Home > Products > Widget, for example) or within a sequence (Step 2 of 4). Next/Previous options should be provided for sequential tasks.

• Allow critical functions to be confirmed and/or canceled/reversed
• Provide adequately-sized clickable targets and ensure functional elements appear clickable

Use labels for form elements, particularly small checkboxes and radio buttons, and ensure all clickable elements appear clickable and do not require exactness.

• Use underline for links only
• Provide multiple methods for finding content

A logical navigation, search functionality, index, site map, table of contents, links within body text, supplementary or related links section, etc. all provide multiple ways for users to find content." (See 7.)

Specific technologies (reference section below and how they use it differently)

To do: Add section

Summary Existing research and guidelines

To do: Add literary summary.

Guidelines

• Cognitive Web Accessibility Checklist (Last Updated September 2, 2009). WebAIM, Center for Persons with Disabilities, Utah State University.
• Friedman M, Bryen D (2007). Web accessibility design recommendations for people with cognitive disabilities. Technology and Disability; 19(4): 205-212.
• Designing websites suitable for people with autism spectrum disorders (Last Updated March 16, 2008). The National Autistic Society.
• 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.
• Telecommunications Problems and Design Strategies for People with Cognitive Disabilities (Last Updated August 16, 1999). World Institute on Disability.

Extent to which current needs are met

   To do: Review challenges and describe where needs are met. Identify gaps 

Potentials and possibilities

Notes for further research:

1. Add RDF implementation from Lisa Seeman's Natural Language Usage - Issues and Strategies for Universal Access to Information.
2. Review accommodation possibilities in "Accommodating Students with Disabilities in Science, Technology, Engineering, and Mathematics (STEM)" (PDF). See info starting on page 93.
3. Review accommodations listed in Katie Haritos-Shea's online course, "Accessible Science Classrooms," specifically the information on accommodations, starting in Module 7: Autism Spectrum Disorders.

Prevalence

The United States Centers for Disease Control and Prevention estimate 1 in 68 children has been identified with autism spectrum disorder. The data show autism spectrum disorders are almost five times more common in boys than girls; and more common in white children than African-American or Hispanic children. (See 3.) Studies in Asia, Europe, and North America have identified individuals with ASD with an average prevalence of about 1%. (See 1.) A study in South Korea reported a prevalence of 2.6%. (See 4.)

References to research.

1. Autism Spectrum Disorder (ASD): Data & Statistics, United States Centers for Disease Control and Prevention, 24 March 2014.
2. Autism Spectrum Disorder (ASD): Facts About ASD, United States Centers for Disease Control and Prevention, 20 March 2014.
3. Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years — Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, Surveillance Summaries; 63(SS02): 1-21, Jon Baio, Editors. National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 2014.
4. Prevalence of autism spectrum disorders in a total population sample, American Journal of Psychiatry; 170(6): 689, Y. Kim, B. Leventhal, Y. Koh, et. al., 2013.
5. Cognitive Disabilities, WebAIM, Center for Persons with Disabilities, Utah State University, 9 August 2013.
6. Executive Function Skills and Disorders, WebMD, LLC., 16 April 2012.
7. Cognitive Web Accessibility Checklist, WebAIM, Center for Persons with Disabilities, Utah State University, 2 September 2009.
8. Book Excerpt: A Web for Everyone, UX Magazine, 7 April 2014.
9. A Web for Everyone: Designing Accessible User Experiences, S. Horton, W. Quesenbery, January 2014.
10. Autism Challenges and Avoidances, Interview of Anonymous User X, N. Milliken, J. Grainger, 17 June 2014.