Universal Access in the Information Society

, Volume 18, Issue 4, pp 891–907 | Cite as

Personalized technology-enhanced training for people with cognitive impairment

  • Maria Claudia Buzzi
  • Marina Buzzi
  • Erico Perrone
  • Caterina SenetteEmail author
Long Paper


Today, ICT technology offers mobile, customized user-friendly environments to support learning and stimulate an individual’s potential. However, technology-enhanced learning tools are usually designed without accessibility in mind, undermining the inclusion of people with special needs. To reduce this gap, we have created a Web platform for delivering accessible games to individuals who may benefit from cognitive training, such as people with down syndrome (DS). The platform offers a personalized environment for learning and training that applies the principles of behavioral analysis. We used participatory design, involving special-needs teachers and psychologists in both design and development phases, to better understand user requirements and create attractive and effective games. A group of 11 children and young adolescents with DS were recruited from ONLUS AIPD (Italian Association of People with Down Syndrome) to test the platform’s usability, observe participants’ responses, and evaluate the limits and strong points of this educational approach. The findings of this study highlight the importance of motivation and flexibility in personalizing content, difficulty levels, and pace for people with DS. Based on this experience, a few basic guidelines have been proposed to refine protocols for accessibility tests with people with DS to maximize engagement, increase usability and collect more feedback to help researchers in designing usable tools/games. Crucial aspects of computerized cognitive training are personalization, system adaptability and monitoring. Strengthening these features could improve user motivation, ensuring continuity of the intervention, making tele-rehabilitation tools usable and beneficial not only for people with DS but also for a broader audience.


Computer-enhanced learning Web applications Cognitive games People with special needs Down syndrome Cognitive training 



Our thanks to the children, families, and all the staff members supporting the AIPD ONLUS (Pisa Section) and participating in the usability test. Special thanks to the pilot and test participants—and the MIUR (Ministero dell’Istruzione, dell’Università e della Ricerca) (2014–2018), which funded the Città Educante Project: PON 2007-2013-Italian Technology Cluster for Smart Communities.


  1. 1.
    Abbeduto, L., Murphy, M.M.: Language, social cognition, maladaptive behavior, and communication in Down syndrome and fragile X syndrome. Developmental language disorders: from phenotypes to etiologies, pp. 77–96. Lawrence Erlbaum Associates (2004).
  2. 2.
    Artoni, S., Pelagatti, S., Buzzi, M.C., Buzzi, M., Senette, C.: Technology-enhanced discriminative programs for children with autism. Proc. of the 8th International Conference on Pervasive Computing Technologies for Healthcare, pp. 331–334 (2014)Google Scholar
  3. 3.
    Bargagna, S., Bozza, M., Buzzi, M.C., Buzzi, M., Doccini, E., Perrone, E.: Computer-Based Cognitive Training in Adults with Down’s Syndrome. Universal Access in Human-Computer Interaction. Universal Access to Information and Knowledge, pp. 197–208. Springer International Publishing, New York (2014)CrossRefGoogle Scholar
  4. 4.
    Bartesaghi, R., Guidi, S., Ciani, E.: Is it possible to improve neurodevelopmental abnormalities in Down syndrome? Rev. Neurosci. 22(4), 419–455 (2011)CrossRefGoogle Scholar
  5. 5.
    Beck, S.J., Hanson, C.A., Puffenberger, S.S., Benninger, K.L., Benninger, W.B.: A controlled trial of working memory training for children and adolescents with ADHD. J. Clin. Child. Adoles. Psychol. 39(6), 825–836 (2010)CrossRefGoogle Scholar
  6. 6.
    Bellotti, F., Berta, R., De Gloria, A., D’ursi, A., Fiore, V.: A serious game model for cultural heritage. J. Comput. Cult. Herit. (JOCCH) 5(4), 17 (2012)Google Scholar
  7. 7.
    Bennett, S.J., Holmes, J., Buckley, S.: Computerized memory training leads to sustained improvement in visuospatial short-term memory skills in children with down syndrome. Am. J. Intell. Dev. Disabil. 118(3), 179–192 (2013)CrossRefGoogle Scholar
  8. 8.
    Bergman Nutley, S., Söderqvist, S., Bryde, S., Thorell, L.B., Humphreys, K., Klingberg, T.: Gains in fluid intelligence after training non-verbal reasoning in 4-year-old children: a controlled, randomized study. Dev. Sci. 14, 591–601 (2011). CrossRefGoogle Scholar
  9. 9.
    Bird, E.K.R., Chapman, R.S.: Sequential recall in individuals with Down syndrome. J. Speech. Hear. Res. 37, 1369–1381 (1994)CrossRefGoogle Scholar
  10. 10.
    Bjork, R.A., Dunlosky, J., Kornell, N.: Self-regulated learning: beliefs, techniques, and illusions. Annu. Rev. Psychol. 64, 417–444 (2013)CrossRefGoogle Scholar
  11. 11.
    Boot, W.R., Kramer, A.F., Simons, D.J., Fabiani, M., Gratton, G.: The effects of video game playing on attention, memory, and executive control. Acta Physiol. (Oxf). 129(3), 387–398 (2008). (ISSN 0001-6918) CrossRefGoogle Scholar
  12. 12.
    Bruni, M.: 2006. Fine motor skills for children with down syndrome, 2nd edn. Woodbine house, Bethesda. CrossRefGoogle Scholar
  13. 13.
    Buzzi, M.C., Buzzi, M., Perrone, E., Rapisarda, B., Senette, C.: Learning games for the cognitively impaired people 2016, W4A ‘16 Proceedings of the 13th Web for All Conference (2016)Google Scholar
  14. 14.
    Carr, J.: The development of intelligence. In: Lane, D., Stratford B. (eds.) Current Approaches to Down’s Syndrome, pp. 167–186. Holt, Rinehart and Winston, London (1985)Google Scholar
  15. 15.
    Chapman, R.S., Hesketh, L.J.: Behavioral phenotype of individuals with Down syndrome. Mental. Retard. Dev. Disabil. Res. Rev. 6, 84–95 (2000)CrossRefGoogle Scholar
  16. 16.
    Das, J.P., Divis, B., Alexander, J., Parrila, R.K., Naglieri, J.A.: Cognitive decline due to aging among persons with Down syndrome. Res. Dev. Disabil. 16(6), 461–478 (1995). (ISSN 0891–4222) CrossRefGoogle Scholar
  17. 17.
    Eldevik, S., Jahr, E., Eikeseth, S., Hastings, R.P., Hughes, C.J.: Cognitive and adaptive behavior outcomes of behavioral intervention for young children with intellectual disability. Behav. Modif. 34(1), 16–34 (2010). CrossRefGoogle Scholar
  18. 18.
    Feng, J., Lazar, J., Kumin, L., Ozok, A.: Computer usage by young individuals with Down syndrome: an exploratory study. In: Proceedings of the 10th international ACM SIGACCESS conference on Computers and accessibility, pp. 35–42. ACM (2008). (ISBN: 978-1-59593-976-0)
  19. 19.
    Feng, J., Lazar, J., Kumin, L., Ozok, A.: Computer usage by children with Down syndrome: challenges and future research. ACM Trans. Access. Comput. (TACCESS). 2(3), 13 (2010). CrossRefGoogle Scholar
  20. 20.
    Gamberini, L., Barresi, G., Maier, A., Scarpetta, F.: A game a day keeps the doctor away: a short review of computer games in mental healthcare. J. CyberTher. Rehabil. 1(2), 127–145 (2008)Google Scholar
  21. 21.
    Garris, R., Ahlers, R., Driskell, J.E.: Games, motivation, and learning: a research and practice model. Simul. Gaming. 33(4), 441–467 (2002). CrossRefGoogle Scholar
  22. 22.
    Goldsmith, T.R., LeBlanc, L.A.: (2004). Use of technology in interventions for children with autism. J. Early Intensive Behav. Interv. 1(2), 166. CrossRefGoogle Scholar
  23. 23.
    Green, C.S., Bavelier, D.: Enumeration versus multiple object tracking: the case of action video game players. Cognition. 101(1), 217–245 (2006). CrossRefGoogle Scholar
  24. 24.
    Hannafin, M.J., Land, S.M.: The foundations and assumptions of technology-enhanced student-centered learning environments. Instructional Science, vol 25, pp 167–202. Kluwer Academic Publishers, Dordrecht (1997)
  25. 25.
    Hasselbring, T.S., Williams, C.H.: Use of computer technology to help students with special needs. Child. Comput. Technol. 10(2), 102–122 (2000). CrossRefGoogle Scholar
  26. 26.
    Hayes, G.R., Hirano, S., Marcu, G., Monibi, M., Nguyen, D.H., Yeganyan, M.: Interactive visual supports for children with autism, Springer Personal and Ubiquitous Computing. (2010). CrossRefGoogle Scholar
  27. 27.
    Hu, R., Feng, J., Lazar, J., Kumin, L.: Investigating input technologies for children and young adults with Down syndrome. Univ. Access Inform. Soc. 12(1), 89–104 (2013). CrossRefGoogle Scholar
  28. 28.
    Jaeggi, S.M., Buschkuehl, M., Jonides, J., Perrig, W.J.: Improving fluid intelligence with training on working memory. Proc. Natl. Acad. Sci. USA 105, 6829–6833 (2008). CrossRefGoogle Scholar
  29. 29.
    Jarrold, C., Baddeley, A.D.: Verbal short-term memory in Down syndrome. J. Speech Lang. Hearing Res. 45, 531–544 (2002)CrossRefGoogle Scholar
  30. 30.
    Kirijian, A., Myers, M., Charland, S.: Web fun central: online learning tools for individuals with Down syndrome. Universal Usability: Designing Computer Interfaces for Diverse Users, pp. 195–230. Wiley, Chichester (2007)Google Scholar
  31. 31.
    Krahmer, E., Ummelen, N.: Thinking about thinking aloud: a comparison of two verbal protocols for usability testing. IEEE Trans. Prof. Commun. 47(2), 105–117 (2004). CrossRefGoogle Scholar
  32. 32.
    Kumin, L., Lazar, J., Feng, J.H., Wentz, B., Ekedebe, N.: A usability evaluation of workplace-related tasks on a multi-touch tablet computer by adults with Down syndrome. J. Usabil. Stud. 7(4), 118–142 (2012)Google Scholar
  33. 33.
    Lloyd, J., Moni, K.B., Jobling, A.: Breaking the hype cycle: using the computer effectively with learners with intellectual disabilities. Down Syndr. Res. Pract. 9(3), 68–74 (2006). CrossRefGoogle Scholar
  34. 34.
    Lo Presti, E.F., Bodine, C., Lewis, C.: Assistive technology for cognition (understanding the needs of persons with disabilities). IEEE Eng. Med. Biol. Mag. 27(2), 29–39 (2008). CrossRefGoogle Scholar
  35. 35.
    Lohaugen, G.C., Antonsen, I., Haberg, A., Gramstad, A., Vik, T., Brubakk, A.M., Skranes, J.: Computerized working memory training improves function in adolescents born at extremely low birth weight. J. Pediatr. 158, 555–561 (2011). (ISSN 0022–3476) CrossRefGoogle Scholar
  36. 36.
    Martins, T., Carvalho, V., Soares, F., Moreira, M.F.: Serious game as a tool to intellectual disabilities therapy: Total challenge. In: 2011 IEEE 1st International Conference on Serious Games and Applications for Health (SeGAH), pp. 1–7. (2011).
  37. 37.
    Mirenda, P.: Toward functional augmentative and alternative communication for students with autism: manual signs, graphic symbols, and voice output communication aids. Lang. Speech Hearing Serv. Sch. 34, 203–216 (2003). Scholar
  38. 38.
    Nielsen, J.: First rule of usability? Don’t listen to users. The Alertbox: current issues in web usability. html (2001). Accessed 1 Sept 2017
  39. 39.
    Nouchi, R., Taki, Y., Takeuchi, H., Hashizume, H., Akitsuki, Y., Shigemune, Y., Kawashima, R.: Brain training game improves executive functions and processing speed in the elderly: a randomized controlled trial. PloS one. 7(1), e29676 (2012). CrossRefGoogle Scholar
  40. 40.
    Olesen, P.J., Westerberg, H., Klingberg, T.: Increased prefrontal and parietal activity after training of working memory. Nat. Neurosci. 7, 75–79 (2004)CrossRefGoogle Scholar
  41. 41.
    Putnam, C., Chong, L.: Software and technologies designed for people with autism: what do users want?. In Proceedings of the 10th international ACM SIGACCESS conference on Computers and accessibility, pp. 3–10. ACM (2008). (ISBN: 978-1-59593-976-0) Google Scholar
  42. 42.
    Robertson, G.L., Hix, D.: Making the computer accessible to mentally retarded adults. Commun. ACM. 45(4), 171–183 (2002). CrossRefGoogle Scholar
  43. 43.
    Rogers, P.: The cognitive psychology of lottery gambling: a theoretical review. J. Gambl. Stud. 14(2), 111–134 (1998). CrossRefGoogle Scholar
  44. 44.
    Rogers, Y.: New theoretical approaches for HCI. Ann. Rev. Inform. Sci. Technol. 38(1), 87–143 (2004)CrossRefGoogle Scholar
  45. 45.
    Sauro, J.: Do users fail a task and still rate it as easy. (2009). Accessed 02 May 2017
  46. 46.
    Sauro, J., Lewis, J.R.: Correlations among prototypical usability metrics: evidence for the Construct of Usability. In: Proceedings of the Conference in Human Factors in Computing Systems (CHI 2009) New York, NY, USA, pp 1609–1618. (2009).
  47. 47.
    Schapiro, M.: (1988). Alzheimer’s disease in premorbidly normal persons with the Down’s syndrome: Disconnection of neocortical brain regions. R. Friedland (Moderator). Alzheimer’s disease: Clinical and biological heterogeneity. Ann. Intern. Med., 109, 298–311CrossRefGoogle Scholar
  48. 48.
    Shneiderman, B.: Universal usability. Commun. ACM 43(5), 84–91 (2000). CrossRefGoogle Scholar
  49. 49.
    Söderqvist, S., Nutley, S.B., Ottersen, J., Grill, K.M., Klingberg, T.: Computerized training of non-verbal reasoning and working memory in children with intellectual disability. Front. Hum. Neurosci. 6, 271 (2012). CrossRefGoogle Scholar
  50. 50.
    Terlecki, M.S., Newcombe, N.S.: How important is the digital divide? The relation of computer and videogame usage to gender differences in mental rotation ability. Sex Roles 53, 433–441 (2005) CrossRefGoogle Scholar
  51. 51.
    Terrace, H.S.: (1963). Discrimination learning with and without “error.” J. Exp. Anal. Behav. 6, 1–27. CrossRefGoogle Scholar
  52. 52.
    Thorell, L.B., Lindqvist, S., Nutley, B., Bohlin, S., Klingberg, G.: T. Training and transfer effects of executive functions in preschool children. Dev. Sci. 12, 106–113 (2009). CrossRefGoogle Scholar
  53. 53.
    Tomé, R.M., Pereira, J.M., Oliveira, M.: (2014). Using serious games for cognitive disabilities. In: Serious Games Development and Applications, pp. 34–47. Springer International Publishing, New YorkCrossRefGoogle Scholar
  54. 54.
    Upadhyay, N.: M-Learning- a new paradigm in education. Int. J. Instr. Technol. Distance Learn. 3(2), 31–34. (2006). Accessed 2 May 2017
  55. 55.
    Winders, P.: Gross motor skills in children with down syndrome: a guide for parents and professionals. Woodbine House, Bethesda (1997). CrossRefGoogle Scholar
  56. 56.
    Wiseman, F.K., Al-Janabi, T., Hardy, J., Karmiloff-Smith, A., Nizetic, D., Tybulewicz, V.L., Strydom, A.: A genetic cause of Alzheimer disease: mechanistic insights from Down syndrome. Nat. Rev. Neurosci. (2015). CrossRefGoogle Scholar
  57. 57.
    Woodward, J., Rieth, H.: A historical review of technology research in special education. Rev. Educ. Res. 67(4), 503–536 (1997). CrossRefGoogle Scholar
  58. 58.
    World Health Organisation: Genes and chromosomal diseases. Accessed 15 Jun 2017
  59. 59.
    Zangari, C., Lloyd, L., Vicker, B.: Augmentative and alternative communication: an historic perspective. Augment. Altern. Commun. 10(1), 27–59 (1994). (Taylor & Francis) CrossRefGoogle Scholar
  60. 60.
    Zigman, W.B., Devenny, D.A., Krinsky-McHale, S.J., Jenkins, E.C., Urv, T.K., Wegiel, J., Schupf, N., Silverman, W.: Alzheimer’s disease in adults with Down syndrome. Int. Rev. Res. Ment. Retard. 36, 103–145 (2008). CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.IIT (Institute of Informatics and Telematics)CNR (National Research Council)PisaItaly

Personalised recommendations