Computer Usage by Children With Down Syndrome: Challenges and Future Research

Computer Usage by Children with Down
Syndrome: Challenges and Future Research 13

JINJUAN FENG and JONATHAN LAZAR
Towson University
LIBBY KUMIN
Loyola University
and
ANT OZOK
UMBC
Children with Down syndrome, like neurotypical children, are growing up with extensive exposure
to computer technology. Computers and computer-related devices have the potential to help these
children in education, career development, and independent living. Our understanding of com-
puter usage by this population is quite limited. Most of the software, games, and Web sites that
children with Down syndrome interact with are designed without consideration of their special
needs, making the applications less effective or completely inaccessible. We conducted a large-
scale survey that collected computer usage information from the parents of approximately six
hundred children with Down syndrome. This article reports the text responses collected in the
survey and is intended as a step towards understanding the difficulties children with Down syn-
drome experience while using computers. The relationship between the age and the specific type of
difficulties, as well as related design challenges are also reported. A number of potential research
directions and hypotheses are identified for future studies. Due to limitations in survey method-
ology, the findings need to be further validated through hypothesis-driven, empirical studies.
Categories and Subject Descriptors: H.5.0 [Information Interfaces and Presentation]:
General; K.4.2 [Computers and Society]: Social Issues—Assistive technologies for persons with
disabilities
General Terms: Human Factors
Additional Key Words and Phrases: Down syndrome, computer use, children, human-computer
interaction
Author’s addresses: J. Feng and J. Lazar, Department of Computer and Information Sciences,
Towson University, 7800 York Road Rm. 477, Towson, MD 21252-0001; email: jfeng@towson.edu;
L. Kumin, Loyola University, 4501 North Charles Street, Baltimore, MD 21210; A. Ozok, UMBC,
Baltimore, MD 21250.
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c 2010 ACM 1936-7228/2010/03-ART13 $10.00 DOI: 10.1145/1714458.1714460.
http://doi.acm.org/10.1145/1714458.1714460.
ACM Transactions on Accessible Computing, Vol. 2, No. 3, Article 13, Pub. date: March 2010.
13: 2 · J. Feng et al.
ACM Reference Format:

Feng, J., Lazar, J., Kumin, L., and Ozok, A. 2010. Computer usage by children with down
syndrome: Challenges and future research. ACM Trans. Access. Comput. 2, 3, Article 13 (March
2010), 44 pages. DOI = 10.1145/1714458.1714460. http://doi.acm.org/10.1145/1714458.1714460.
1. INTRODUCTION
Increasing attention has recently been drawn in the Human-Computer In-
teraction (HCI) community towards the design and development of accessible
computer applications for individuals with developmental or cognitive impair-
ments (e.g., Dawe [2006; 2007]; Mohamed et al. [2006]). Due to better health-
care and education, the quality of life has improved for people with Down
syndrome (DS). Children with DS grow up and live in the community and are
surrounded by technology. Compared to the neurotypical children or children
with other types of developmental disabilities, children with DS can be consid-
ered fairely unique in that all three major types of capabilities (cognitive, mo-
tor, and perceptual) are affected but the disability often is mild [Cohen 1999].
Therefore, the child’s computer usage is subject to the combined impact of lim-
itations in multiple channels, making it more difficult to accommodate than
those cases where only one single channel is affected. In addition, the gap
in intellectual skills between children with DS and their neurotypical peers
increases as they grow older, requiring the design to constantly adapt to the
evolving needs of the population [Carr 1985]. Although the characteristics of
DS are thoroughly studied and documented, our knowledge is very limited on
how these characteristics affect the development of computer skills and the
adoption of information technology.
We conducted an online survey that was designed to collect information on
existing computer usage by children with DS. Approximately 600 parents of
children with DS responded to the survey and provided information on their
children’s general computer usage behavior. More importantly, this survey
generated, for the first time, extensive information on the difficulties experi-
enced by children with DS when interacting with computers. Getting a better
understanding of what exactly children with DS know about computers, and
how they use them, can help researchers and practitioners develop more effec-
tive interfaces targeted specifically towards this population. It can also provide
insights to improve educational programs that teach appropriate computer,
language, and professional skills leading to increased employment opportuni-
ties and a better quality of life.
This article discusses the difficulties reported by parents about their chil-
dren’s computer use and the possible underlying causes. The first section pro-
vides a review of existing literature on the characteristics of DS as related
to computer usage, and the studies in HCI and special education fields that
involve children with DS. The following section describes the design of the
survey, the data collection and analysis procedure, the demographic informa-
tion of the sample, and the general categories of difficulties experienced by
children with DS when interacting with computers. The next five sections fo-
cus on cognitive difficulties, physical difficulties, software-related difficulties,
Computer Usage by Children with Down Syndrome · 13: 3
societal and educational factors, and the impact of age. Typical comments and
examples provided by the parents are directly cited to help the reader under-
stand each type of difficulty. In the last few sections, we discuss the implica-
tions of the findings, the limitations of the study, and suggestions for future
research.
2. RELATED RESEARCH
2.1 Causes and Characteristics of Down Syndrome

Down syndrome is a genetic impairment that occurs in about 1 out of 800 live
births in the United States [Centers for Disease Control and Prevention 2006].
There are three different types of chromosomal abnormalities that may be the
underlying cause of the DS in an individual: trisomy 21 (90%–95% of the popu-
lation), translocation (3%–5% of the population), and mosaicism (2%–5% of the
population) [Devlin and Morrison 2004]. Trisomy 21 and translocation both
lead to the same clinical characteristics. There is very little research available
about mosaic DS, which appears less severe as compared to the other two types
because not all the cells are affected. Most previous studies do not specify the
specific cause, but recent publication policies have noted a need to include this
information [Buckley 2009]. The present survey investigation included chil-
dren with all three types of DS in a sample that adequately represents the
distribution of the three types of DS in the population.
Down syndrome affects an individual’s overall development, including the
areas of cognitive, linguistic, sensory perception and processing, and gross and
fine motor skills. Those areas that are affected contribute to greater difficulty
in communication skills than would be expected according to the cognitive level
[Abbeduto et al. 2001; Kumin 2003]. The characteristics presented in a spe-
cific child may also be related to additional coexisting conditions that occur
at higher rate than in the general population, such as autism spectrum disor-
ders [Fombonne 2003], attention deficit hyperactivity disorder [Capone et al.
2006], and childhood apraxia of speech [Kumin 2006a; 2006b]. Using autism
as one example, the incidence of autism is about 7%–10% in children with DS
as compared to 1 in 150 in the general population [Capone 2002].
Regarding cognitive skills, most individuals with DS have mild to moderate
intellectual disabilities as reflected in IQ scores in the range of 40–70. They
have more difficulty compared to their neurotypical peers in abstract think-
ing, short-term memory, and attention span. Their visual-spatial memory is
typically stronger than the auditory-verbal memory [Bird and Chapman 1994;
Chapman and Hesketh 2000; Kumin 2003]. The gap in intellectual capabilities
between children with DS and neurotypical children increases as the children
grow older [Carr 1985]. This is reflected in the typical decline in IQ scores as
children with DS grow older despite various intervention techniques [Sloper
et al. 1986].
Regarding linguistic skills, individuals with DS experience delayed develop-
ment in expressive language (speaking) and their receptive language is supe-
rior to expressive language. In other words, individuals with DS are better at
understanding what others say than expressing their own thoughts verbally
[Buckley and Bird 2001; Chapman and Hesketh 2000; Buckley and Johnson-
Glenburg 2008]. Individuals with DS have relative strength in vocabulary and
everyday social language but substantial difficulty with grammar [Berglund
et al. 2001; Chapman and Hesketh 2000], auditory-verbal short-term mem-
ory [Kanno and Ikeda 2002], and complex conversational skills [Hopmann and
Wilen 1993; Kumin 2008]. Due to both physical and cognitive limitations (e.g.,
low muscle tone, difficulty with memory for verbal information), individuals
with DS tend to have reduced speech intelligibility (understandable speech)
[Abbeduto and Murphy 2004; Chapman and Hesketh 2000].
In the area of motor skills, both fine motor (e.g., cutting with scissors) and
gross motor (walking) skills are delayed [Bruni 2006; Winders 1997]. Low
muscle tone and weak muscles are often a problem. The research and clinical
literature also report difficulties in the sensory areas of hearing [Roizen 1997;
Shott 2000], vision [Roizen et al. 1994], and tactile (touch) [Bruni 2006].
In the last decade, significant research has been conducted to identify the
phenotype (characteristics) that occur with the genotype of trisomy 21. The
findings have documented that the characteristics of DS are connected to other
developmental disabilities such as autism, fragile X syndrome, and Williams
syndrome in multiple aspects, but the cognitive, physical, and social phenotype
as a whole is highly distinctive [Abbeduto and Murphy 2004; Abbeduto et al.
2001; Landa 2007; Laws and Bishop 2004; McElwee and Bernard 2002; Rice
et al. 2005; Roberts et al. 2007; Rogers et al. 2001]. First, multiple channels
of abilities (most notably cognitive and physical) are affected by the syndrome
but the disability tends to be mild or moderate. In this aspect, Down syndrome
is similar to fragile X syndrome and Williams syndrome, but very different
from conditions that affect specific functions such as aphasia or dyslexia. The
fact that DS affects all three channels of human abilities suggests that lessons
learned from studying people with disabilities in a single channel can not be
readily applied to individuals with DS because the difficulties in other chan-
nels introduce additional challenges. Second, children with DS make progress
in intellectual skills as they grow, but at a substantially slower rate compared
to their neurotypical peers [Carr 1985]. As a result, the gap in intellectual
skills between individuals with DS and their neurotypical peers increases from
infancy to adulthood, as reflected in decreasing IQ scores. This trend is also
observed in males with fragile X syndrome. But other populations such as chil-
dren with autism, children with Williams syndrome, and females with fragile
X syndrome generally show stable IQ scores as they grow older and sometimes
even increased IQ scores in response to intervention [Venter et al. 1992]. Be-
cause the educational and entertainment software and materials on the Web
are designed according to the developmental pace of neurotypical children,
older children with DS may experience more problems due to the increasing
gap than younger children. Third, maladaptive behaviors such as social anxi-
ety and attention deficit occur at lower rates among individuals with DS com-
pared to children with Autism, Fragile X syndrome, and Williams syndrome,
who typically experience more frequent problems in social interaction (e.g.,
Wing and Gould [1979] and Phillips et al. [1998]). This comparative strength
may potentially affect the motivation of computer use as well as the interaction
styles of the children. For instance, it has been reported that young children
with DS tend to use their social skills as a tool to avoid solving challenging
problems [Wishart 1993].
Although the characteristics of DS are thoroughly studied and well under-
stood, there appears to be a disconnection in the literature between those char-
acteristics and their impact on the everyday computer usage by children with
DS. In other words, we know these characteristics can potentially affect a va-
riety of computer usage activities. For example, difficulties in abstract think-
ing, short-term memory, and attention span affect general problem solving and
learning activities when using computers. The impact on fine motor skills and
muscle tone may play a role when the individual uses a variety of input de-
vices such as the mouse, keyboard, and trackballs. However, there is a lack
of empirical or qualitative data that allow us to map these characteristics to
the specific activities affected and further evaluate the extent to which these
activities are affected.
2.2 Computer Usage as Related to Individuals with Down Syndrome

Existing research in Universal Accessibility (UA) related to users with DS is
quite limited. Studies that examine cognitive disabilities started to emerge
only in the past decade. For instance, Cohone et al. [2007] worked on devel-
oping reminiscence tools for users with Alzheimer’s Disease. Wu et al. [2007]
developed tools for people with amnesia. Moffatt et al. [2004] developed tools
for people with aphasia. A field that has drawn increasing attention both in
the general public and in academia is the study of children with autism and the
attempt to improve their language development and social skills via computer-
mediated software or agents (e.g., Lehman [1998], Hart [2005], and Tartaro
and Cassell [2008]). In addition to developing technologies to be used by chil-
dren with autism themselves, researchers also explored technologies to assist
the children’s caregivers in communication, record collection and analysis, de-
cision making, and assessment of the children’s internal states (e.g., Kientz
et al. [2007]). A few studies investigated users with DS together with users
with various other cognitive impairments (e.g., Dawe [2006, 2007]). These
studies provide valuable insights regarding the impact of cognitive impair-
ments on the use of computer-related activities. But due to fundamental dif-
ferences between conditions such as Alzheimer’s disease, amnesia, aphasia,
Autism, and DS, observations and findings from these studies can not be read-
ily applied to people with DS.
Researchers in special education are to some extent informed of the poten-
tial of computer technology in helping individuals with DS (e.g., Buckley [2000]
and Black and Wood [2003]). They claim that computer technology can help
people with DS increase confidence and motivation through creative activities
and Web browsing. Computer technology also has other benefits, including
errorless learning, patient feedback, immediate feedback, self-paced learning,
and independence of learning. However, Lloyd et al. [2006] suggested that
the actual benefits of computer technology may be reduced or not apparent
depending on the quality of the software. First, the contents of many software
programs are not age appropriate. Second, many educational software pro-
grams are unable to reach educational goals and are used as a tool for mere
entertainment. Third, many programs do not promote independent learning.
The empirical study conducted by Ortega-Tudela and Gomez-Ariza [2006]
examined the impact of an educational software program on learning mathe-
matical counting skills. Eighteen children with DS participated in the study.
Ten of those children used multimedia education software to learn basic count-
ing skills and the other eight tried to learn the same counting skills via the
traditional paper-and-pencil approach. After 15 sessions, children who used
the educational software demonstrated significantly higher performance than
those who used paper and pencil. The authors suggested that children who
used educational software benefit from the integration of auditory and visual
information, personalized task sequences that help to address attention deficit
and working memory limitations, and the presentation of animated objects
that helps overcome deficits in abstract thinking.
It is important to examine how assistive (or standard) technologies could
help individuals with DS be more independent, yet remain connected to oth-
ers and in touch with caregivers, to get assistance when needed [Lewis 2005].
Dawe [2006; 2007] examined how young adults with cognitive impairments
and their families adopt assistive technology. The participants in the study
included a combination of individuals with DS, autism, or other unspecified
developmental delays or disabilities. Two separate studies were completed,
one focusing on assistive technologies in general, the other focusing on mobile
phone usage. The study concluded that different individuals or groups are in-
volved in the adoption process at different stages and the objectives of these
individuals may be different. For example, parents want the school system
to introduce and support the best technology available for their children (e.g.,
touchscreen), but teachers tend to prefer technology with which a student is
already familiar (e.g., mouse). A few participants did not use a cell phone be-
cause they could not connect the ringing tone of the phone with the idea that
someone is trying to reach them. Participants had difficulty with navigation
menus that had too many options. The primary design guideline from the
Dawe study is to keep the design small and simple.
Although there is little research on computer usage of individuals with DS,
there is one well-documented design case for this population [Kirijian and My-
ers 2007]. The National Down Syndrome Society worked with a Web design
firm to develop a Web site specifically designed for people with DS, called Web
Fun Central. The goal was to teach Web browsing and other computer skills
specifically to teenagers with DS. Six individuals with DS became part of the
design team and took part in usability testing sessions. Two separate usabil-
ity tests, both involving the same six participants, were completed to inform
the design. As a part of this process, the researchers were able to develop
a number of guidelines for designing Web sites and computer-based learning
modules for people with DS. While the project provided valuable lessons for
design and development, the guidelines and findings need further verification
due to its small sample size. Most of the guidelines proposed are also similar to
general design heuristics (e.g., provide clear guidance, feedback, and rewards).
The question on how Web design for individuals with DS is different from the
general public therefore remains unanswered.
Despite the potential benefit of the usage of multimedia and educational
software for individuals with DS and the potential that computer technology
may provide for individuals with DS, our understanding is rather limited re-
garding whether and how individuals with DS use computers in their every-
day lives. There appears to be a substantial need of baseline information on a
number of topics, including the basic computer skills people with DS naturally
possess, the objectives for using computers, and the difficulties they experience
while using computers. Knowledge on these issues will help researchers and
practitioners form a concrete and accurate picture of this unique population,
and understand how to help individuals with DS make better use of technol-
ogy. This was the major motivation for us to conduct the national survey on
computer usage by children with DS.
Part of the survey results were previously reported in Feng et al. [2008]. For
the 561 children studied in the survey, 83% started using computers by age six.
Most of the children use computers for learning (80%) and entertainment (95%)
purposes. The most commonly used computer applications include educational
software, computer games, and the Internet. Keyboard (85.6%) and mouse
(93.2%) are the most commonly used input devices. Although widely adopted,
keyboard usage is challenging for the children surveyed. 49.6% of the children
can only type using one index finger, 27.9% can type using two index fingers,
11.7% can type using two or more fingers on one hand, and only 10.8% can type
using multiple fingers on both hands. Parents reported that the children spent,
on average, 3.5 hours a week on the computer at school (standard deviation =
3.12) and 4.94 hours a week at home (standard deviation = 5.13).
The data reported in Feng et al. [2008] document that children with DS are
capable of using computers in their everyday life for a variety of activities.
However, we need to acknowledge that the technology usage percentage only
reflects part of the big picture. The numbers were generated by categorizing
children using a simplistic, binary approach, namely, whether or not the child
uses a specific technique or application. This approach fails to reveal the ways
and contexts in which the technology is being used [Dawe 2006]. The majority
of the parents provided detailed text descriptions about various problems and
challenges that their children experience when using computers. This arti-
cle reports on findings from the text descriptions and provides an overview
of the computer-related problems and challenges experienced by children
with DS.
3. RESEARCH METHODS
3.1 Survey Design

We developed a 56-question survey on the use of computers by children with
DS (see Appendix A for the complete collection of survey questions). The sur-
vey questions were designed to target for children who are currently using
computers. The data collected does not reflect children who do not use com-
puters, and therefore would not be representative of all children with DS.
The questions were split into four sections: general computer usage, interac-
tion techniques [Zevenbergen 2007], usage of personal electronics, and demo-
graphic and background information [Debell and Chapman 2003]. The survey
included a combination of multiple-choice questions with only one option to be
checked, multiple-choice questions where respondents could check as many as
applied, Likert scales, and open-ended questions.
The survey instrument was pilot tested to improve the clarity of questions.
The language and wording of the survey questions were carefully selected
to make sure the targeted audiences fully understood the meaning of each
question. The use of technical terms was kept at a minimum. An easy-to-
understand definition was provided in situations where a technical term had
to be used. When information was asked about different categories of applica-
tions or activities, examples for each category were provided.
The study was designed to have parents of children with DS fill out the
survey, rather than having the children themselves fill it out. There were
two reasons for this approach. First, there was some concern that even the
older children might have trouble understanding some of the questions. Sur-
vey responses from parents were likely to be more accurate. Second, it was
unclear that children with DS would be able to fully understand the need for
informed consent and be able to give their consent. In addition, the use of
proxy users (either caregivers or close relatives) is considered acceptable in
research on users with disabilities and has been adopted in a number of suc-
cessful studies that examined conditions such as aphasia, autism, and locked-
in syndrome (e.g., Allen et al. [2007], Dawe [2006], Dawe [2007], and Doble
et al. [2003]). Compared to researchers who can only observe participants for
a limited amount of time, parents have the advantage of continuously observ-
ing their children in natural settings. On the other hand, the use of proxy
users also has its limitations. What we collected reflects what the parents
observed and there might be situations or challenges that the parents did
not capture. Therefore, the challenges that we will discuss in the following
sections are not intended to be an exhaustive collection of what the children
experience.
3.2 Data Collection

After the questions were developed, the survey was transformed for the Web.
Design guidelines were followed to ensure that the survey was easy to use
[Lazar and Preece 1999]. An announcement about the survey was made on
a number of listservers for parents of children with DS (e.g., the Chesapeake
Down Syndrome Group), and on the Web sites of two major Down syndrome
organizations in the U.S.A. (National Down Syndrome Congress and National
Down Syndrome Society). Flyers were distributed at the National Convention
of the National Down Syndrome Congress. To accommodate the needs of fam-
ilies who did not have Internet access, hardcopies of the survey were sent to
participants upon request. No incentives were provided in this study.
3.3 Data Collected and Content Analysis Procedure

Information about 600 children with DS was collected via the survey.
Responses to the closed-ended questions on demographics, the objectives of
using computers, the types of applications used and Web sites visited, as well
as the interaction techniques were reported in Feng et al. [2008]. This arti-
cle discusses the responses to Questions 29 and 30 of the same survey (see
Appendix A):
—“What are the common difficulties your child has, if any, using the com-
puter?”
—“What potential solutions, if any, can you suggest to the problems your child
has or may have using the computer?”
Among the 600 responses, 39 were excluded in Feng et al. [2008] because the
age information was either missing or out of the targeted age range of the
study (4–21), reducing the sample size to 561 children. The data reported in
this article describes 513 of the 561 children whose parents provided text de-
scriptions to questions 29 and 30. 237 of the 513 children were female. The
children were between 4–21 years old. The majority of the children were school
aged, with approximately 51% between ages 5–10, 17% between ages 11–13,
and 22% between ages 14–18. Most of the children started using computers
at a very young age, with 74% starting by age 5 and nearly 90% starting by
age 7. 495 parents provided information about their children’s current or past
(in cases when the child had graduated from high school) education settings.
Approximately 57% of the 495 children attended mainstream classes in reg-
ular schools, 27% attended special education classes in regular schools, 11%
attended special education schools, and 5% were home-schooled. For more de-
tailed information on the computer usage statistics of the participants, consult
Feng et al. [2008].
The responses to Questions 29 and 30 contain approximately 22,700 words.
Information obtained from the dataset covers underlying problems, usage pat-
terns, and interaction strategies as related to computer applications. Content
analysis was conducted on the text dataset. Due to the lack of literature in this
domain, the objective of the content analysis was not to develop a construct or
model to explain the difficulties reported in the survey. Instead, the goal was
to provide a summary of the difficulties that children with DS experience when
using computers. In the first stage of the content analysis, three researchers
read through the responses and identified high-level categories such as: cogni-
tive difficulties, typing difficulties, mouse difficulties, reading difficulties, and
frustration. These high-level coding schemes, although helpful, have specific
limitations in the context of our survey. The majority of the respondents did
not specify high-level difficulties, but provided detailed instances of the prob-
lem that their children experienced, such as “difficulty in using passwords,”
“difficulty in clicking the mouse,” “hard to engage in real conversation,” etc.
Only documenting the high-level coding categories would not reflect the rich
information provided by the parents. Moreover, grouping each individual low-
level instance to high-level categories can be tricky. For example, “difficulty in
13: 10 · J. Feng et al.
using passwords” may be attributed to both cognitive limitations that make it

difficult to remember passwords and physical limitations that make it difficult
to enter passwords. Therefore, documenting high-level coding categories when
it was not clearly specified by the respondents would require substantial in-
terpretation from the coder and the results could be biased. To address these
limitations, we took a detail-oriented approach in the second stage and tried to
document any instances of difficulties reported by the parents. In this stage,
one researcher coded the responses and documented all the coding items she
identified. After that, another researcher conducted a reliability check on the
first researcher’s coding to identify any additional coding items and instances
that were missed or coded incorrectly. The overall agreement between the two
coders is satisfactory. The first coder made a total of 1076 codes. Among them,
1015 (94%) codes were kept by the second coder. In addition, the second coder
added 154 codes. So the final set contains a total of 1169 codes, 87% of which
were agreed upon by both coders. 86 coding items were documented in the fi-
nal set (see Appendix B for a complete list of the coding items). The number of
occurrences for each coding item in the 513 responses was counted.
To help the readers understand the results, we summarized the coding
items into a multi-level tree structure (see Figure 1). In the tree structure,
each subcategory only belongs to one parent category. The tree structure was
built based on the authors’ subjective interpretation (e.g., list “frustration” un-
der “cognitive limitations” category, list “typing difficulties” under the “phys-
ical limitations” category) and was only used to summarize the results. In
Figure 1, the numbers in parentheses represent the number of children whose
parents reported the difficulty. The subcategories do not add up to the par-
ent category for two reasons. First, a child might experience difficulties in
multiple subcategories under the same parent category (e.g., reading difficulty
and writing/communication difficulty listed under language difficulty). Each
type of difficulty counts as one data point in the corresponding subcategory
(e.g., one under reading difficulty, one under writing and communication dif-
ficulty). However, in the parent category (language), they only count as one
data point because the two descriptions are about the same child. Second, the
parent category also contains data points that were not included in any of its
subcategories. For example, some parents stated that their children’s com-
puter usage was hindered by limited language skills without further explana-
tion. In this case, the response was directly counted in the “language difficulty”
category.
We discuss the findings under each category in the following sections. Some
of the challenges are unique to children with DS (e.g., weak muscle strength,
short fingers), others may be observed among neurotypical children as well
(e.g., difficulty in navigation, difficulty in using mouse) [Hourcade 2006]. Chil-
dren with DS are expected to encounter more challenges than their neutotypi-
cal peers because of the characteristics of the impairment. It is not the purpose
of this article to make direct comparison between children with DS and the
neurotypical children due to the administration of the survey. Further stud-
ies are needed to fully understand the difference between the two populations
regarding computer usage behaviors.
Fig. 1. Summary of difficulties experienced by children with DS (numbers in parentheses repre-

sent the number of children whose parents reported the difficulty).
4. COGNITIVE LIMITATIONS
Three subcategories were listed under cognitive difficulties. They are general
cognitive difficulties, language difficulties, and difficulties caused by frustra-
tion. Language- and frustration-related difficulties were very frequently stated
with approximately one out of four respondents reporting difficulties under ei-
ther of the two categories. 11.8% of the respondents stated difficulties due to
general cognitive limitations.
4.1 Language Difficulties

Language difficulties can be further divided into two categories: reading dif-
ficulty and writing and communication difficulty. 16.9% of the respondents
reported reading difficulties. 9.3% of the respondents reported writing and
communication difficulties.
4.1.1 Reading Difficulties. Reading problems are not exclusive to children
with DS. Neurotypical children also need time to build their reading skills and
experience similar problems (e.g., Chall [1983], Braunger and Lewis [2005],
and Mateos et al. [2008]). However, children with DS experience more sub-
stantial problems with reading and these problems persist as they mature
(e.g., Cardoso-Martins et al. [2008]). Although children with DS demonstrate
stronger reading abilities than language and number abilities, their reading
13: 12 · J. Feng et al.
abilities are typically two years behind their age in primary school [Buckley
and Bird 2001]. However, the gap is likely to increase as the child gets older.
A study in the U.K. suggested that approximately 35% of teenagers with DS
could not read at 8–9 years level, which is considered to be the bottom line for
independent reading. The reading abilities for teenagers in special schools fall
further behind [Buckley et al. 2001].
Limited reading skills affect computer usage in multiple aspects. Parents
reported that children with DS find it very hard to understand and follow text-
based instructions of applications and Web sites. This is particularly prob-
lematic during the initial interaction with a piece of software or a Web site.
Parents often have to sit together with their children and show them step by
step how to accomplish a specific task. Limited reading skills also make it
hard to navigate within applications, menus, or Web sites because the children
could not understand the keywords in the menu or the instructions. The fol-
lowing quotes suggest iconic language combined with text for key navigation
functions may work better for children with DS. For all the quotes, the number
in the parentheses following the quote states the age of the child.
“She has trouble reading the words like exit or start...sometimes she
just clicks on things until she gets places”.(6)
Reading problems make it difficult to retrieve information on the Internet and
cause frustration among the children.
“[His difficulty is] understanding how to find things (search, se-
lect links to click <overwhelming number of results>, find what
he needs on the page) on the Internet; overwhelming number of
words on a page, has a hard time following the words. . . difficulty
understanding some directions; frustration leading to giving up. . .
he would benefit from programs which offer auditory instructions
rather than requiring reading.” (13)
Limited reading skills make the children highly vulnerable to errors and un-
expected outputs.
“[His difficulty] is in problem solving...if computer isn’t “working”
like he wants it to, he gets frustrated. He can’t read the error mes-
sages so needs someone always nearby.” (7)
Lack of reading skills also makes it difficult for children to take full advantage
of computers and the Internet as a communication tool.
“[Her difficulty is] lack of reading skills, lack of socialization that en-
able her to chat, . . . she uses sign language, pecs (picture exchange
communication system [Bondy and Frost 2001]), some speech to
communicate and that needs to be incorporated into the programs.”
(14)
The parent responses suggest that the difficulty in reading with traditional
books extends to on-screen reading. Software or games designed for neurotyp-
ical children may require reading levels not appropriate for children with DS.
Table I. Example Comments from Parents Regarding Writing and Communication Difficulties
Age Description
14 “Another problem is answering who, what, why questions appropriately and
participating in a real conversation. If the activities were geared to these
difficulties and articulation difficulties it would help in all areas of her life.”
17 “He would love to send emails to his family and friends but spelling and composing
are challenges. We are looking into voice activated word processing for him.”
21 “Email and chat are not rewarding experiences, too slow and difficult.”
And when the reading level of the software is appropriate for the child, the in-
terest level and presentation of the material may be too immature for the child.
4.1.2 Writing and Communication Difficulties. Most children with DS

have age appropriate social and emotional skills similar to those of neurotypi-
cal children [Buckley et al. 2002]. Adolescents with DS want to communicate
and want to socialize [Cohen 1999; McGuire and Chicoine 2006]. Although
there are a large number of individuals with DS, they live in diverse geo-
graphical settings. There is a problem with isolation and depression among
adults with DS that, perhaps, could be impacted by the use of email or
other computer-based communication tools (such as bulletin boards or Internet
conferencing with a Web camera) to maintain an ongoing friendship and con-
nection [McGuire and Chicoine 2006]. However, the difficulty in writing and
communication seems to be a major obstacle for achieving this goal.
Children with DS experience more delay in writing and communication
skills compared to reading skills. They can understand more than they can
say or write, likely due to difficulties in word retrieval, sentence structure, and
speech motor control [Buckley and Bird 2001]. Similar to reading, the difficulty
in writing also extends to the context of computer use. According to parents,
spelling is a big challenge for children with DS when writing emails, letters,
or other types of responses. Parents report that their children’s writing is very
hard to understand due to frequent spelling errors. Children with DS also find
it hard to come up with appropriate words. Individuals with DS are generally
friendly and sociable in nature, and they normally can respond appropriately
at the beginning of conversations. But it is difficult to put together electronic
messages that can get them engaged in real conversation. The parents also
reported that their children have difficulty answering critical questions such
as who, when, where, what, and why questions. These comments reflect the
literature that individuals with DS have relative strength in everyday social
language but great difficulty in grammar and complex conversational skills
[Kumin 2008]. Table I lists feedback from a number of parents under this
category.
Among parents who answered the survey, those of children from 14 and
above noted writing and communication difficulties more often than parents
of younger children. This finding is in line with existing literature that as
children with DS get older, their development rate does not keep pace with
neurotypical children and the gap between them and neurotypical children be-
comes larger [Carr 1985]. The increased social needs for distance communica-
tion in late teens may also contribute to the increasing cases of communication
13: 14 · J. Feng et al.
difficulties. Among the 513 children in this sample, only 23% of those aged be-
low 14 use computers for communication purposes. In contrast, 46% of those
aged 14 and above use computers for communication purposes.
4.2 Frustration
Parents reported children with DS frequently get frustrated when using com-
puters. Frustration can be attributed to four major sources: navigation prob-
lems, difficulty in trouble shooting, lack of patience, and design flaws.
4.2.1 Navigation. Navigation is reported to be a big challenge for children

with DS when they use software applications, work with the WindowsTM file
system, and browse the Internet. Simply initiating and exiting an application
can be difficult for young children. Interacting with the application menus to
find specific functions is even more challenging.
“She doesn’t know how to get in and out of programs at this time,
but she could possibly learn this.” (8)
“[His difficulty is] learning how to use the options on MS WordTM
(font size, paragraphs, sentence structure, etc.)” (14)
Web navigation is another big problem for children with DS. Compared to regu-
lar application software such as WordTM or Media PlayerTM , browsing the Web
presents a double challenge. Similar to regular application software, the user
needs to learn to interact with the static menu of a Web browser. But learning
the browser menu alone is far from sufficient for the purpose of browsing the
Web. The children also need to recognize the links on a specific page, learn the
overall structure of the site, get the sense of orientation, and be able to track
the path to and from a specific page. An even more difficult task is coping with
large amounts of information that are frequently updated and reorganized.
“When he is online he doesn’t understand about pop-ups and can
run into trouble with clicking on the wrong thing to try to close a
box, etc. Or he’ll end up with too many windows open at once and
things will freeze up or not work right.” (14)
In addition to common navigation problems such as finding a specific item in
a menu, finding a file, and locating a specific Web page, respondents reported
other navigation problems including difficulty in viewing email attachments
and entering the URL of a Web site. It was also reported that children tend to
open an excessive number of windows, which may cause problems such as loss
of spatial orientation or long system response time.
4.2.2 Trouble Shooting. Parents reported that children with DS have very
low error tolerance and are therefore vulnerable to unexpected interruptions
or problems. Many children depend on a routine process that they remember
to get into specific Web pages or applications. They may get stuck if a single
step goes wrong during that process and they have very limited understanding
concerning why an error occurs or what to do to fix it.
“He cannot resolve a problem if he opens a window that he did not

intend to open or clicks on a Web site he does not intend [to click].
Therefore, he needs a companion to correct those types of errors.
Otherwise he sits and sobs.” (9)
Frequently reported problems that cause frustration also include long system
response time and pop-up advertisements.
“Occasionally our computer at home will freeze up. This really frus-
trates our daughter–but heck it frustrates me too :-) Sometimes we
can talk her through the issue, sometimes she just gives up and asks
for help.” (11)
4.2.3 Lack of Patience. Parents reported that children with DS are impa-
tient in using technology. They do not like to wait and frequently get frustrated
when application software or a Web page takes substantial amount of time to
load. When using educational software or playing online games, they expect
obvious and ready answers and can get frustrated when the answer is not
straight forward. Some parents commented as follows.
“His patience level is low and he does not do well yet in sitting and
listening to anyone else try to teach him how to use various pro-
grams or Web sites.” (8)
“[Her difficulty is the] lack of patience with computer games and
educational software. If the answer is not easily achievable, she
doesn’t have the patience to try multiple things. Instructions need
to be simple and short. She doesn’t have the patience for learning
the keyboard at this point and struggles if the mouse click “range”
is too small.” (8)
4.2.4 Design Flaws. Some frustrations can be attributed to design flaws.

For individuals with DS, the information presented to them when using com-
puters can be too overwhelming to handle. Parents reported that searching
for information online using search engines is challenging for their children.
First, it is very hard for the children to come up with appropriate keywords
for the information they want to search. Second, search engines return over-
whelmingly large numbers of records for them to filter through. Web sites and
educational software also tend to provide long and complicated instructions
that are beyond their reading and understanding capabilities.
“Web pages in general are too full of STUFF to easily seek out the
information of interest. (I think they are visually overwhelming for
me!) . . . Some drop-down menus in software are too long for easy
navigation.” (18)
Interestingly, some children find effective alternatives to help them identify
the appropriate search keyword:
“[He doesn’t have] spelling ability to navigate Web sites. However,
he’s learned to find the keywords in his environment in books, video
13: 16 · J. Feng et al.
tapes, etc., and then copy the word into a search engine such as
Google to find Web sites that he’d like to visit.” (13)
Another commonly made design flaw is inconsistency. Parents reported that

the children got confused when the same function key responded differently
in different applications. Some Web sites and software have mismatching text
and contents, making it very hard for their children to find appropriate infor-
mation. There is also possibly mismatch between instructions and feedback.
“Mostly she has trouble adapting between different control systems.

For example, if the shift key does one thing in one program, she has
a hard time dealing with it if it does something else in a different
application.” (14)
Frustration with computers has been documented for both the general com-
puter users [Ceaparu et al. 2004] and users with visual disabilities [Lazar et al.
2006]. However, frustration may have greater impact on children with DS due
to their limited cognitive and language abilities. Children with DS who have
higher language and communication skills experience less frustration because
they can explain what happened, how they feel, and what they want [Buckley
et al. 2002]. The lack of language and communication skills may be one factor
that causes the nine-year old boy to “sit and sob” when a problem occurs. To
address this challenge, we need to think of ways to reduce the incidents or de-
sign features that may induce frustration. Equally important, we also need to
help children with DS learn how to deal with frustration when they encounter
problems.
4.3 General Cognitive Difficulties

The third category comprises general cognitive difficulties that do not directly
relate to either language capabilities or frustration. Abstract thinking skills
are substantially delayed for children with DS [Bird and Chapman 1994;
Chapman and Hesketh 2000]. Parents reported that it is difficult for their
children to understand key concepts and establish associations between the
computer world and the real world. For example, children have difficulty un-
derstanding the connection between specific icons and their functions, such as
the use of the recycle bin icon for deleted items. Icons tend to be abstract and
their functions are often not obvious. These comments are interesting consid-
ering parents also noted that visual design with icons might be an effective
solution to help children with DS overcome difficulties in understanding in-
structions, menus, and navigation links.
Parents reported that many children with DS could not understand the wide
potential and scope of computers, only considering computers as an entertain-
ment tool. They have problem understanding the concept of menus, and the
connection between menu items and their functions. The limitation in under-
standing concepts and associations makes the initial encounter with software
or Web sites particularly challenging.
“[His difficulty is] probably understanding the connection to the out-

side world...it’s a concept, and many concepts are difficult to under-
stand...” (16)
In addition to difficulties in understanding concepts, children with DS also

have limited memory capabilities [Bird and Chapman 1994]. Parents have
to sit together with their children, and show them many times how to use
software or a Web site, before they can complete tasks independently. This
is frustrating for both parents and their children. Parents state that time is
a determining factor in the adoption of computers for their children. If they
spend the time with their children, they can see progress. But they are gener-
ally stretched too thin to spend a sufficient amount of time with their children
on computer-related activities. On the other hand, children like to use the
computer independently and can get discouraged or frustrated if their parents
keep watching them over their shoulders.
Due to attention deficit [Capone et al. 2006; Alton 1998], some children with
DS can not concentrate on a task or a Web site for a sufficient period of time.
Parents reported that the children do not like completing tasks under time
pressure. The default time limits on solving a problem, preset on many edu-
cational software or game Web sites, are too short for children with DS. In ad-
dition, parents reported that finding appropriate materials for their children
was very hard.
“Many educational games are based on speed of response, and he

can’t keep up. I find this problem especially with math and typing
programs.” (14)
“Her comprehension skill level is below an average child her age.

This means she is slower than her peers in completing tasks. . . .
She has difficulty working within the time constraints given by the
sites she is using.” (8)
5. PHYSICAL LIMITATIONS
DS has a substantial impact on physical capabilities. Children with DS usually
have small hands and short fingers, low muscle tone, and limited fine motor
skills [Bruni 2006]. All these characteristics have implications for the use of
standard input devices. Small hands and short fingers make it hard to reach
the keys on a standard keyboard or mouse. Children with low muscle tone can
experience frequent tiredness or muscle pain after using computers for a short
period of time. The manipulation of the keyboards and mice require fine mo-
tor skills in which children with DS experience substantial delay compared to
their neurotypical peers. According to the Feng et al. [2008] results, more than
22% of respondents reported difficulties in typing. More than 10% reported
difficulties in using the mouse. 9% of respondents reported general physical
limitations without specifically stating the computer usage functions affected
by the limitations.
13: 18 · J. Feng et al.
5.1 Typing Difficulty

Parents reported that difficulty with typing is one of the dominant obstacles
that prevent children from fully exploring the potential of computers. Very few
of the children, even those aged 15 and above, can touch-type. The majority of
the children use the “hunt and peck” method when writing WordTM documents,
emails, or instant messages. “Hunt and peck” is a very slow method, and the
text generated has frequent spelling and grammar errors. The children also
have problems using the function keys.
“His short fingers make it difficult to do standard touch-typing so he
is more a hunt and peck kind of guy.” (17)
The typing difficulty reported reflects the characteristics of DS in the existing
literature. Typing is a complicated task that requires not only sophisticated
fine motor skills, but also substantial literacy skills in language, spelling, and
writing. Learning touch typing also requires high memory load. Children with
DS experience delays in the development of all these areas. Therefore, most
children with DS experience great difficulty in typing through their adolescent
years. The Feng et al. [2008] survey responses suggest that very few of the
children eventually acquire the ability of touch-typing.
5.2 Mouse Difficulty

Mouse usage is very common among children with DS, with more than 93%
of the participants currently using a mouse [Feng et al. 2008]. Many par-
ents stated that their children use the mouse without much difficulty. These
responses are actually better than our original expectation based on the ex-
isting literature that children with DS have limited fine motor skills and poor
hand-eye coordination. However, the result needs to be interpreted with cau-
tion because the survey only targeted children who already use computers.
Although the overall performance is encouraging, 10% of the respondents re-
ported mouse-related difficulties. Specific challenges include the selection of
small targets, double clicking, and the use of a mouse that is too sensitive.
“He does not have the dexterity to use the mouse on small objects.
He does fairly well if the item to be clicked is larger.” (9)
“[He has difficulty in] locating the alphabet, mouse control, click
control (e.g., double versus single click, right versus left click,
space/locating click), general typing skills (e.g., shift, backspace,
delete), and application selection from desktop (e.g., email versus
Internet, WordTM versus PowerpointTM).” (10)
6. SOFTWARE PROBLEMS
Parents reported a variety of software-related challenges, ranging from access
problems to design flaws. More than 12% of participants reported difficulty
accessing appropriate software. Overall, there is a severe lack of software pro-
grams designed for children with cognitive disabilities. Existing software is
not effectively distributed, making the situation even worse. As one parent
states:
“. . . although my child could do many more things than he is do-
ing on the computer, his computer experience has always been lim-
ited by the software that software companies bother to write and
how “accessible” that software is to children with poor receptive lan-
guage skills. There are many activities in software programs that
he is capable of doing, cognitively, but which are not offered with
simple enough instructions on how to work the software itself, and
therefore limit his ability to participate.” (13)
A major challenge for software design for children with DS is the discrepancy
between the developmental pace of cognitive and analytical capabilities and
the developmental pace of preferences and tastes. Existing literature suggests
that children with DS are quite competent in social and emotional perspectives
that affect a person’s preference and taste [Buckley et al. 2002]. As they get
older, their preference and tastes become more mature, but their motor and
cognitive capabilities, especially the latter, lag behind. This means that they
need to learn skills that are typically acquired at a much younger age for neu-
rotypical children. For instance, a ten-year old child with DS might need to
learn simple mathematical skills that are typical for a seven-year old. Most of
the programs or games available for him are designed with features that have
appeal for typically developed, 7-year old children (e.g., childish cartoon char-
acteristics with exaggerated tones and gestures). Those features might seem
naı̈ve and boring for children with DS who are chronologically 10 years old.
This creates a paradox: children with DS normally outgrow the programs or
games that teach them the skills that they need to learn. The following are a
group of sample messages from parents with similar concerns:
“He is a 14-year old boy at a kindergarten level, and he would like
to have more “cool,” age-appropriate programs at his level.” (14)
“I would say that the difficulty is now that he is 14, it is difficult
to find appropriate computer fun software for him. The early learn-
ing [software] are too young for him, and the teen programs are too
difficult.” (14)
The challenge of developing software or games with the appropriate levels of
content and design presentation is also observed among other user popula-
tions. Henderson et al. [2005] developed a computer game to help deaf chil-
dren learn American Sign Language. They found that the original game was
not challenging enough for some children and one child even added advanced
sign language that was not included in the corpus. A corresponding redesign
provided the motivation for children to play the game longer. Similar prob-
lems have also been observed among children who speak English as a second
language (e.g., Duff [2006]).
Parents also reported a number of design flaws in computer software and
games. Note that design flaws are previously discussed in the section of causes
13: 20 · J. Feng et al.
for frustration, where the focus is on flaws that induce frustration. In this sec-
tion, the discussion focuses on design flaws that do not necessarily incur frus-
tration, but reduce the efficacy of the software or prevent users from achieving
the desired objectives.
In addition to excessive information and inconsistent design, parents re-
ported that inappropriate responses frequently cause problems for the chil-
dren. Positive feedback for failed attempts, designed to encourage children,
may lead to unexpected and undesired interaction patterns.
“A big distraction is the positive feedback he gets from selecting
wrong answers. He likes to hear the responses so he often selects
wrong answers just to hear the response, then he laughs about it.”
(10)
These kinds of negative reinforcement are highly problematic because they
may cast negative impacts on the skills and knowledge that children have
already acquired. Another related comment suggests that software with too
many entertainment elements may not be beneficial for learning. The rela-
tionship between the entertainment elements and the learning elements in
software is interesting and more research is needed to verify the claim.
“[There is] too much distraction built into the programs. Too much
entertainment and not enough materials that require the child to
work, click, or respond to get a stimulus on the screen. The best
programs are the ones that do not entertain but require a response
from the child. . . ” (8)
7. SOCIETAL DIFFICULTIES
7.1 Curriculum
Parents reported that computer education for children with cognitive disabil-
ities is not currently recognized as an important area of learning for children
with DS. Many schools do not offer computer courses in which children with
DS can enroll. Even when these courses are offered, they are not accompanied
by materials or instructions designed to help children with DS. Well-trained
teachers or programs that teach computer skills for children with DS are very
hard to find. Most computer learning appears to be happening at home. Pro-
grams that train parents with both computer knowledge and skills for teaching
children with DS are highly recommended by parents as an area of need.
“I think one of the first solutions is influence a change of mind
set...we need to encourage the education community to look at merg-
ing academics with function. I would begin by adding a computer
curriculum to a school districts program. I would suggest that spe-
cial ed. programs and assistive tech specialists have more tools
available to them for the enhancement and encouragement of com-
puter use for children with DS. They need to have a broader knowl-
edge base of how academics and daily living skills can be adapted
and modified with the use of computers. Professionals should be

more knowledgeable about Web sites and software that are available
and there should be extended time frames to try/test these products
for successful integration into a child’s school and home life.” (10)
“I would love to see a college for special needs adults focused on
training them and helping them obtain employment in computer-
based fields, such as data entry, hospital forms, customer service,
mail order.” (20)
7.2 Security and Privacy

Parents expressed concerns regarding security and privacy threats that their
children face in the online environment. Children with DS can be very friendly
and trusting, which makes them highly vulnerable to online predators. Close
monitoring of children’s online activities is considered highly necessary but
hard to achieve for two reasons. On one hand, children do not like to be
watched over the shoulder all the time. On the other hand, most parents do
not have the time to closely monitor their children’s online activities.
“I think we also worry about inappropriate online situations where
she would be especially vulnerable. Our home computers contain
our business records so we hesitate to give our children open ses-
sions on them.” (14)
“I wouldn’t like her to know how to get into chat rooms and end up
online with a predator. She is naı̈ve and believes when someone says
they are 17. . . they are in fact that age. I have to monitor who she
is chatting with on AOL IM.” (17)
“I am reluctant to turn my child loose on the Internet. She clicks
sometimes randomly, and if she were tired of an online game and
click[s] out, who knows where she’d end up. If I have to supervise
the Web access–she won’t spend much time on the Internet. Is it
possible to program the computer with 6, 10, 25 appropriate Web
sites that a child can visit, preventing her access to the rest of the
Web?” (15)
The first comment is informative in that it highlights the level of risk when
the design of security mechanisms does not accommodate the needs of the chil-
dren: both children and their parents or other family members may become
victims. The idea of a role-based system may help in addressing the need to
protect information on a shared computer [Long and Moskowitz 2005]. The ob-
servation that the children spend less time on the Internet under supervision
than when they are not supervised also needs further examination. Privacy
issues might be one possible reason that contributes to children’s aversion for
supervision. Another parent of a boy aged 15 stated:
“My son needs some help in learning how to access information that
interests him. He also needs to be reminded to check his email. He
13: 22 · J. Feng et al.
is not confident with his spelling so often he needs me to type his

reply. I guess if I was to spend more time with him on the computer
that would help. He will be 16 soon and he doesn’t want mom to see
what his interests are.” (15)
This comment suggests the conflict between the children’s need for timely as-
sistance and supervision and their equally important need for personal pri-
vacy. Children with DS are facing a dilemma in computer usage. On one hand,
they are not capable of using computers independently and need frequent help
from their parents on a variety of tasks. On the other hand, they desire that
some, if not all, of their computer and online activities be kept private, even
from their parents. The fact that both comments are from children aged in
their mid-teens provides insights on when privacy needs emerge among these
children.
In addition, the dominant user name and password authentication mech-
anism is reported to be problematic for children with DS. Due to cognitive
impairments, it is very hard for children with DS to understand why the mech-
anism is needed and how it works. It is also highly challenging for them to re-
member the user name and password for a specific account because of limited
memory. Finally, due to limited typing skills, errors are highly likely to occur
when they enter the user name and password. It is particularly problematic
when the authentication mechanism requires a “strong password” with more
than eight characters containing both uppercase and lowercase letters. Par-
ents reported that they have to enter the user name and password for their
children in many cases. This challenge prohibits the children from accessing
a large number of free online services and resources independently. The next
quote is interesting in that it suggests the need for password help acts as an
unexpected but convenient supervision tool for parents.
“. . . She has to get someone to do the password for her, so we know

when she’s on. . . otherwise I think she’d wake up early and be on-
line, LOL. . . ” (8).
8. IMPACT OF AGE ON COMPUTER USAGE

The abilities of children evolve with age. The design of computer applications
for children has to consider the age of the targeted user group. The impact
of age is especially important for children with DS because their intellectual
skills develop at a slower pace compared to the neurotypical children. Regres-
sion analyses were conducted to explore the underlying patterns or trends of
the difficulties that children with DS experience at different ages. The inde-
pendent variable of the regression is age on a year by year basis. The depen-
dent variables of the regression are the percentages of children whose parents
reported the difficulty. We do not intend to use the regression to establish an
accurate quantitative relationship between age and the percentage of children
experiencing a specific type of difficulty. In other words, we only want to know
whether a significant trend exists in the data, not how to accurately define that
trend.
Fig. 2. Percentage of children whose parents reported difficulty in navigation or trouble shooting.
Similar to the rest of the findings, the regression has its limitations in that
parents might miss specific difficulties that their children encountered. How-
ever, due to the large sample size, we do not think this limitation threatens
the validity of the regression as long as the focus is on the overall trend, not
the accurate prediction of the percentages. It is possible that the actual per-
centage of children experiencing specific types of difficulties is higher than the
reported percentages, suggesting that the actual percentage-age curve might
be higher than those shown in Figures 2, 3, and 4. But the overall pattern
shown in these curves is unlikely to change because the difficulties missed by
the parents would affect all age groups. We also analyzed potential outliers
for the regression analyses. No outliers were identified for the regression on
trouble shooting difficulties. One or two outliers were identified for the other
regression analyses (i.e., age 15 for navigation difficulty; age 11 for reading
difficulty; ages 14 and 21 for writing/communication difficulty; age 4 for mouse
difficulty; age 14 for typing difficulty). According to the high leverage index hi,
the outliers only affect the parameter estimation, not the significance of the
overall trend.
Figure 2 demonstrates the relationship between age and the percentage of
children whose parents reported difficulty in navigation or trouble shooting. A
regression analysis shows that there is a quadratic relationship between age
and the percentage of children experiencing navigation difficulties (F (2, 15) =
6.69, p < 0.01). The peak years during which children with DS experience
navigation difficulties is between ages ten and fifteen. A linear relationship
exists between age and the percentage of children experiencing difficulties in
trouble shooting (F (1, 16) = 8.46, p < 0.05). For older children, difficulties in
trouble shooting were reported less often than for younger children.
Figure 3 demonstrates the relationship between age and the percentage of
children who experienced difficulty in reading or writing/communication. A
regression analysis shows that there is a quadratic relationship between age
and the percentage of children experiencing reading difficulties (F (2, 15) =
13: 24 · J. Feng et al.
Fig. 3. Percentage of children whose parents reported difficulty in reading and writing/
communication.
reading difficulties is between ages nine and fourteen. A linear relationship
exists between age and the percentage of children experiencing writing and
communication difficulties (F (1, 16) = 29.24, p < 0.001). For older children,
difficulties in writing and communication were reported more often than for
younger children.
Figure 4 demonstrates the relationship between children’s age and the per-
centage of children who experienced difficulty in using mouse or typing. A
regression analysis shows that there is a linear relationship between age and
the percentage of children experiencing difficulty in using a mouse (F (1, 16) =
34.4, p < 0.001). For older children, difficulties in using a mouse were reported
less often than for younger children. A quadratic relationship exists between
age and the percentage of children experiencing typing difficulties (F (2, 15) =
typing difficulties is between ages ten and fifteen.
Besides the overall age-related trends shown in the regressions, there is, at
least for a subset of the children, a possible trend of decreased computer us-
age after the children complete school. Some parents of older children with
DS reported that their children lost interest in computers although they fre-
quently used computers for educational or entertainment purposes when they
were younger. As several parents stated:
“She is no longer interested in using the computer. We used it for her
education (home-educated her from birth through 12th grade). She
spends all day working at the skill center and relaxes with music at
home.” (21)
“She was using the computer for education software more in the past
but has lost interest lately.” (20)
More information needs to be collected to verify these claims. If this pattern
is found to be common among children with DS, it may indicate that existing
Fig. 4. Percentage of children whose parents reported difficulty in using a mouse and typing.
educational programs and computer applications fail to establish a concrete

connection between computer knowledge and skills and the everyday needs of
individuals with DS. In other words, the great potential that computers and
technology can offer has not yet been tapped.
9. IMPLICATIONS
Built on top of existing knowledge about children with DS and general design
issues for children, the current study made a step towards closing the gap be-
tween the well-understood characteristics of DS and their impact on computer
usage, which itself is not well understood. It expands our knowledge of user
needs and computer usage behavior of children with DS and provides implica-
tions for design, the general research approach, as well as future research.
9.1 Implications of Unique Characteristics of DS for Design

There are three unique characteristics of DS that are closely related to com-
puter usage: the condition’s impact on multiple channels of capabilities; the
gap between children with DS and their neurotypical peers that increases with
age; and the comparative strength in social skills. According to the survey
results, the limitations in cognitive, language, and motor skills all have pro-
found impact on computer usage as reflected in difficulties reported in memory,
timely processing of information, understanding abstract concepts, reading,
writing, and communication, navigation, typing, and the use of the mouse.
9.1.1 Impact of Limitations in Multiple Channels. When the user only has
one specific type of disability, the designer can adopt alternative techniques
that employ abilities that are not affected. For example, speech recognition is
recommended for users with physical disabilities in hands and arms but in-
tact speech functions. However, since DS affects multiple channels of abilities,
designers may find that the solutions to address problems in one aspect may
not work well due to limitations in other channels. Using speech input as an
13: 26 · J. Feng et al.
example, a substantial number of parents proposed the use of speech recog-

nition instead of keyboard because typing is very difficult due to the physi-
cal and cognitive limitations of the children. But designers should keep in
mind that children with DS also have language difficulties that directly af-
fect the performance of speech technology. Another example is the possible
use of text-to-speech technology. Because children with DS have limited read-
ing skills, parents proposed that speech output may be useful to help children
with DS understand instructions, menus, or Web contents. However, children
with DS have very limited auditory-verbal working memory and their visual-
spatial memory is comparatively stronger than their auditory memory. This
means that speech output may demand too much working memory and hin-
der their understanding of the information. The third example is the possible
use of iconic design. On one hand, iconic language may be a better solution
than text information because of the children’s reading difficulties. But on
the other hand, iconic language may introduce additional challenges because
the children may have problems associating the icons to the corresponding
concepts.
In some cases, seemingly unrelated difficulties may work together to exacer-
bate the interaction experience. For example, due to limited fine motor skills,
errors are very likely to occur when children with DS select icons or visit Web
links. Unfortunately, their cognitive limitations make it very hard for the chil-
dren to understand why the error occurs and think of ways to recover from
the error. In this case, children need help from other people to deal with the
errors. Many times the help may not be readily available. Even when help
is available, children may have difficulty explaining the problem to the helper
due to limited language and communication skills.
Currently, we do not know the exact solutions to address these challenges,
but we believe it would be a substantial step forward if the designers become
aware of these challenges. From the academic perspective, understanding and
addressing the combined effect of disabilities in multiple channels is one of the
unique features of Down-syndrome-related research. A number of research
questions can be derived from this perspective regarding the interaction ef-
fects between problems related to two or more channels. For example, we need
to systematically study the gains of using auditory output compared to visually
presented text information. In the meanwhile, we also need to evaluate the po-
tential negative impact of auditory output on working memory. This objective
may require the evaluation variables to go beyond text recall and comprehen-
sion, but rather the overall ability to complete a specific task that involves the
understanding of textual information.
9.1.2 Impact of Age. The survey results suggest that different types of
challenges are more common at specific age ranges. As is shown in Figures 2 to
4, three different trends emerge regarding different types of difficulties asso-
ciated with age. For older children, difficulties in trouble shooting and mouse
usage are reported less often; difficulties in writing and communication are
reported more often; and difficulties in navigation, reading, and typing are
increasingly reported before age ten and gradually decrease during the late
teens. We envision that the different trends are formed as the result of the
combined effect of the children’s developing abilities and their evolving needs
for computers. The pattern for mouse usage shows that difficulty in using the
mouse is more common before a child turns eight. During these years, most
children primarily interact with computers using the mouse but their fine mo-
tor skills are still limited. As the children’s fine motor skills gradually improve,
most children with DS reported in this survey eventually master the skills re-
quired to use the mouse. In contrast, writing and communication difficulties
do not show substantial impact until approximately age ten and the increasing
trend continues well into the late teens.
The quadratic patterns are more complicated and further research is needed
to confirm these patterns and explain their underlying causes. For both read-
ing and typing difficulties, it is hard to explain the decreasing trend in the late
teens because the children’s reading and typing skills remain limited during
those years. Further research is needed to examine the possible causes such
as improved skills, decreased needs for these skills, or intentional avoidance of
tasks involving these skills. Investigation of the possible avoidance strategies
is particularly interesting because avoidance strategies are frequently adopted
by younger children with DS when presented with challenging tasks [Wishart
1993].
These findings provide insights on the needed skills at different age ranges.
It may help if the children are trained for specific skills one or two years
before they typically experience substantial difficulty related to those skills.
For example, mouse skills can be trained early on when the children are five
or six years old, while typing and navigation skills may wait until eight or
nine. Therefore, software that teaches these skills needs to target specific age
ranges. In the meanwhile, the design of software or Web sites for specific age
groups needs to adapt to the challenges that these children typically experi-
ence. Meanwhile, it should be noted that the variable of age is highly corre-
lated with computer experience as reflected by the number of years that the
child has used computers (Person’s r (511) = 0.86, p < 0.001). Thus computer
experience is a significant confounding factor for age. In this study, it is im-
possible to separate the impact of experience from age and further studies are
needed to investigate the two factors.
9.1.3 Impact of Comparatively Strong Social Skills. Children with DS ex-

perience different paces in the development paths of different skill sets. Their
social capabilities usually develop ahead of their cognitive and motor capabili-
ties. This mismatch creates a dilemma for parents when choosing software or
games: those that are appealing to their children teach skills and knowledge
that are too advanced or depend on skills that their child has not yet acquired.
The software that targets skills at the right level tends to be naı̈ve and boring,
not well matched for the child’s age and interests. One possible approach to
address this challenge is allowing the user to customize a software or game by
choosing the functions or materials that the child needs from a candidate list.
Adjustable difficulty levels may also help in closing the gap between the two
sets of abilities.
13: 28 · J. Feng et al.
9.2 Implications for General Design and Research Approach
9.2.1 Addressing User Diversity. One of the most important issues with
the design and research for children with DS is how to address substantial
user diversity. Multiple studies report that people with DS demonstrate wide
individual variation in cognitive, physical, language, and learning capabilities
(e.g., Carr [1985], Chapman and Hesketh [2000], and Mundy et al. [1995]).
Moreover, the delays in different types of skills are not consistent. For in-
stance, in adolescents with DS, the lexical and syntax skills diverge, with lex-
ical comprehension being better than syntax comprehension [Chapman et al.
1991]. The survey results suggest that the wide individual variation among
the DS population is also reflected in computer-related skills and capabilities.
Some parents commented that their children were capable of completing a va-
riety of activities on computers independently, while others need constant as-
sistance. For the population studied in this survey, age is an important factor
that affects children’s capabilities and interests and contributes to substantial
user diversity. An empirical study that examines a limited number of partici-
pants recruited from the general DS population may observe a large variation
in performance that can hardly inform the design. A more effective approach
is to investigate the population through subgroups that are defined according
to the known cognitive, physical, or language skills. This approach has been
adopted for designing virtual peers for children with autism and the results
are promising [Tartaro and Cassell 2008].
Due to the limited scope of this survey, we did not collect information on chil-
dren’s cognitive, physical, language, or learning abilities and therefore could
not discuss the findings according to more targeted subgroups. It should be
noted that the assessment of these abilities can be quite complex and time con-
suming. For instance, the Stanford-Binet Intelligence Scale, a standard test for
assessing intelligence and cognitive capabilities, tests four areas through 15
subtests [Becker 2003]. If the test results are not available for a specific child,
it would take substantial time to run the test and collect the needed informa-
tion. In addition, children with DS do not respond in an “assessment” situation
the same as neurotypical children. The scores of the same closely spaced tests
can fluctuate substantially for the same child, with previously demonstrated
skills disappearing in later tests [Wishart 1998]. Cognitive tests, with a few ex-
ceptions such as the Comprehensive Test of Nonverbal Intelligence, are based
on language, and language skills will affect cognitive scores. Fatigue, lan-
guage skills in understanding instructions, and language skills in terms of
encoding expressive language messages and saying them with understandable
speech when responding will all affect the accuracy of test scores. Researchers
should be well aware of these challenges when defining and studying different
subgroups.
9.2.2 Children with DS and their Neurotypical Peers. For decades, many
researchers believed that the development of children with DS was just a
“slowed-down” version of the development of neurotypical children. How-
ever, studies suggest that there might be fundamental differences in the
development processes. For instance, children with DS are more likely to use
avoidance strategies than their neurotypical peers when faced with cognitive
challenges [Wishart 1993]. When presented a slightly “difficult” cognitive task,
children with DS tend to immediately “opt-out” or engage in diversionary ploys
such as slipping under the table or waving and clapping until the task is aban-
doned. In addition, children with DS only demonstrate interest in tasks that
fall within very narrowly defined cognitive ranges: those slightly more or less
difficult than their current development stage. The lack of interest in both
“easy” and “difficult” tasks means that already acquired skills are not suffi-
ciently exercised and many opportunities for learning new skills are missed.
This may partially explain why the progress made by children with DS is more
unstable compared to their neurotypical peers [Wishart 1993].
To date, our understanding of the difference in the development process is
still limited and further studies are needed to provide more confirmative an-
swers to this question. However, existing evidence of the difference does sug-
gest that the “design for all” approach may have limitations for children with
DS. The needs of children with DS are quite unique and inconsistent regard-
ing their chronological age, so approaches such as lowering the reading level
by two years may not completely solve the problem. The substantial delay in
cognitive, physical, language, and learning abilities, combined with the typical
development pace in social and emotional abilities, presents further challenges
for the delivery of age-appropriate materials that appeal to children with DS.
Theoretically, children with DS are likely to benefit more from software and
Web sites that are well tailored to their abilities and needs, such as the Web
Fun Central Web site discussed earlier in the article. Practically, it is unrealis-
tic to develop a special version of every related software or Web site specifically
for children with DS. Moreover, a recent survey on people with autism found
that existing software for individuals with cognitive disabilities is not quite
successful in reaching the target users. Only 25% of the respondents to that
survey ever used applications designed for people with cognitive disabilities
[Putnam and Chong 2008]. Compared to the “design for one” approach, the
“design for all” approach is more feasible from a cost aspect and may be more
realistic, even if it does not meet the exact needs of users with DS.
9.3 Implications for Future Research
9.3.1 Input Solutions. Further research is needed to help children with

DS enter information into their computers. The Feng et al. [2008] survey data
provides evidence that children with DS have difficulty using traditional input
devices, especially the keyboard. Modifications for existing keyboards and mice
may improve the effectiveness of these devices. However, they are unlikely to
address fundamental challenges caused by delays in both cognitive and motor
capabilities.
One possible input alternative that shows both potential and challenges is
speech recognition. Many parents hold high expectation for speech-based in-
teraction and multiple factors do favor the adoption of speech-based interac-
tion by children with DS. First, unlike children with autism, children with DS
13: 30 · J. Feng et al.
are talkative and sociable. They are expected to be comfortable with a speech-
based interaction style. Second, children with DS type at very slow rates and
the text generated contains frequent spelling and grammatical errors. On
the other hand, the obvious challenge for the adoption of speech technology
is recognition errors [Oviatt 2000]. Although the accuracy of speech recogni-
tion technology has improved dramatically in the past two decades and recog-
nition accuracy rates as high as 98% have been reported [Karat et al. 2003],
recognition errors are unlikely to be eliminated and lab-based studies observed
substantially higher recognition error rates (e.g., Sears et al. [2003]). To fur-
ther complicate the situation, the majority of children with DS have speech
disabilities due to weak muscle power and cognitive delays. Speech intelligi-
bility difficulties affect over 95% of individuals with DS [Abbeduto and Murphy
2004]. Their speech is not as clear as that of a typical child and recognition er-
ror rates therefore might be higher (see the parents’ comment that follows).
Therefore, only those high-functioning children with clear speech may benefit
from speech technology.
“If his speech were clearer, he might benefit from a program that
could type what he says. He could also benefit from a program that
could read the site to him. Maybe there could be a way to highlight
what he wants read. He knows how to highlight items already.” (16)
To date, the actual efficacy of speech technology as used by children with DS
has not been empirically evaluated. Both lab-based studies and ethnographical
examinations are needed to provide benchmark data on text generation speed,
recognition error rates, and the degree of error tolerance. The study of error
tolerance will be interesting in that the children’s attitude towards errors may
be different from their neutotypical peers as a result of their limited typing
skills. Error tolerance may also be affected by the nature of the tasks as well
as the interaction context. In a recent six-month field study, Hu et al. [2009]
observed that adults with upper-body physical disabilities had higher levels
of tolerance for recognition errors when using Instant Messaging than when
using Word. In many cases of misrecognition (e.g., “Hi, dude” recognized as
“Hi, duke”), the user just ignored the errors and sent the messages out without
correcting the errors. Interestingly, the other party also seemed to be fine with
the errors and the communication went on smoothly. It will be interesting to
study whether this type of behavior also occurs among children with DS.
While large vocabulary dictation applications can be challenging for most
children with DS, customized, speaker-dependent speech input techniques
with a small vocabulary that focuses on specific tasks may achieve higher
recognition accuracy and help alleviate frustration related to keyboard usage.
It was reported that customized speech applications improved the performance
of users with dysarthria in both small and large vocabulary task settings (e.g.,
Green et al. [2003] and Manasse et al. [2000]). Regarding the characteristics
of speech, DS is similar to flaccid dysarthria because both cases involve oral
motor difficulties. In contrast to apraxia that typically generates highly in-
consistent errors, oral motor skills difficulty results in very consistent errors,
making the adaptation comparatively easier.
When a speech-based technique is evaluated, the comparison should not

only be made with the traditional keyboard entry method, but also keyboard
input with facilitating mechanisms such as word prediction software. In addi-
tion, multimodal input solutions that allow integrated usage of multiple tech-
niques, such as speech and touchscreen, are also worth further exploration.
9.3.2 Solutions for Information Presentation. Parents frequently sug-

gested the use of icons to deliver information on computers. On one hand,
the advantage of iconic language over text is directly rooted from the funda-
mental characteristics of DS. Due to the genetic disorder, children with DS
experience substantial delays in cognitive capabilities including abstraction
and language, but learn well and process well in visual-spatial areas [Bird and
Chapman 1994]. Therefore, understanding text-based instructions is highly
challenging for children with DS. Iconic language that uses images to deliver
information may help children with DS understand instructions and menus
that are otherwise inaccessible. On the other hand, parents also reported that
children with DS have difficulty understanding the connection between specific
icons and their functions. Many icons presented in games and software are ab-
stract and their functions are not obvious. Even neurotypical users may find
icons hard to guess and understand [Blankenberger and Hahn 1991]. Chil-
dren with DS may find more icons hard to guess due to limited understanding
of concepts and how they relate to each other.
The two conflicting factors demand further research on the design of iconic
language for children with DS. We need to understand what types of images
children with DS like or prefer and what level of abstraction is appropriate
for them. Ideally, a good icon needs to be easily recognizable, guessable, and
should carry a strong logical tie to the underlying concept [Moyes and Jordan
1993]. A concrete icon is generally easier to guess because it closely resem-
bles the underlying function or concept, but it may be hard to recognize when
reproduced on a small screen space. In contrast, an abstract icon is harder
to guess but shows more simplicity. Due to the cognitive limitations of chil-
dren with DS, it is possible that designers need to sacrifice simplicity for easy
guessability and association.
Another solution that needs more research is the use of speech output. Sim-
ilar to iconic language, speech output also has the potential to help addressing
the children’s limitations in one aspect, but its effectiveness may be hindered
by their limitations in other abilities. More studies are needed to examine the
impact of limited auditory-verbal memory on the children’s ability to under-
stand speech output.
9.3.3 The Impact of Age on Computer Usage. Three questions emerge from
the results regarding the impact of age on computer usage. First, the different
patterns in the specific types of difficulties related to age (see Figures 2–4)
need to be verified by more focused studies. The causes for the increasing and
decreasing trends in specific age ranges need to be identified. Second, more
detailed information needs to be collected on the evolving differences between
children with DS and their neurotypical peers regarding computer usage.
13: 32 · J. Feng et al.
Third, the reported loss of interest in computers after the children finish
school needs to be verified. If the lack of interest is common among children
with DS after they finish school, we need to find out the underlying cause and
its implications: Does it lead to healthier lifestyle or does it result in missed op-
portunities? One possible explanation for this phenomenon is that the children
were not provided the opportunity to apply their computer skills and knowl-
edge in the workplace because most of the typical jobs offered to individuals
with DS do not involve the use of computers. However, this hypothesis cannot
explain why these children also stopped using computers at home. Another
possible explanation is that existing computer activities are mainly education-
and entertainment-oriented (e.g., improve math skills, improve reading) and
therefore, although the children benefit from these activities, their commit-
ment to computers decreases as they leave the educational setting or find other
sources of entertainment. According to Feng et al. [2008] results, 95% of the
children use computers for entertainment purposes and 80% use computers
for educational purposes. Only one-third of the children use computers for
communication purposes such as email. If this hypothesis is confirmed, it will
highlight the need to find solutions to transform the acquired computer skills
into practical benefits in the everyday life of children with DS.
9.3.4 Security and Privacy Protection. Viruses, worms, phishing attacks,

spam, and malicious online threats have haunted millions of computers users.
Children with DS are particularly vulnerable to these threats and some par-
ents completely block Internet access for their children due to security- and
privacy-related concerns. In the meanwhile, security and privacy protection
mechanisms, although completely necessary, have become a key interaction
barrier for children with DS. This problem is likely to become more severe as
the security and privacy mechanisms continue to raise the bar for the cognitive
and perceptual abilities involved in order to battle increasingly sophisticated
threats. Passwords are required to include long sequences of uppercase and
lowercase letters, and numbers. Even neurotypical users find passwords, es-
pecially those that are the randomly assigned, hard to remember [Yan et al.
2005]. The CAPTCHA (Completely Automated Public Turing Test to tell Com-
puters and Humans Apart) technique used to block automated programs is
forced to increase the distortion rate to make it more difficult for automated
programs to break [Chellapilla et al. 2005]. Unfortunately, as distortion rates
increase, it becomes more difficult for humans to decode the CAPTCHA while
the performance of automated robots is barely affected [Chellapilla et al. 2005].
One fundamental challenge for the research community is to lower the cog-
nitive demand for existing security- and privacy-related mechanisms while
preserving the desired level of protection. Some recent studies provide in-
sights on password design and cognitive capabilities (e.g., Jermyn et al.
[1999]). Regarding the traditional alphanumeric approach, passwords based
on mnemonic phrases may be more appropriate for children with DS be-
cause they are easier to remember than random passwords and more secure
than naively selected passwords [Yan et al. 2005]. But mnemonic phrase-
based passwords may be more vulnerable to attacks in the near future as
the mnemonic password dictionary becomes more comprehensive [Kuo et al.

2006]. Multiple studies suggest that graphical passwords are easier to re-
member than alphanumeric passwords because graphical passwords require
recognition rather than recall, and human memory for images far exceeds that
for verbal information (e.g., Moncur and Leplatre [2007] and Standing [1973]).
However, a recent study found that, when evaluated under realistic settings
with multiple graphical passwords being used, the passwords interfered with
each other and the login failure rate was ten times higher than when a single
password was used [Everitt et al. 2009].
To date, no study has been conducted to quantitatively examine the char-
acteristics of the alphanumeric passwords that children with DS generated,
which will provide critical information on the robustness of these passwords.
It will be interesting to study whether children with DS can understand and
learn the mnemonic phrase-based passwords. More research is also needed to
investigate the usability of different types of graphical passwords (e.g., cogno-
metric schemes such as facial or art images, locimetric schemes that present a
single image, and drawmetric schemes that require drawing) when being used
by children with DS.
From a broader point of view, new security models that adapt to the chil-
dren’s needs and threats can help in addressing a variety of challenges such as
authentication, file management, and data theft. The Bitfrost security model
developed for the One Laptop per Child project provided valuable insights in
this direction [Krstic and Garfinkel 2007]. Although the threat model for Bit-
frost cannot be readily applied to children with DS due to the different context
of use, the approach to the design security models based on customized threat
models shows great potential. In addition, security and privacy protection for
children with DS is largely dependent on their parents or other caregivers.
One research question worth investigating in this domain is the development
of monitoring systems that allow parents and caregivers to supervise the chil-
dren’s online activities without being too intrusive. It will also be helpful to
develop appropriate educational or training programs to increase the security
and privacy awareness of both children with DS and their caregivers.
10. LIMITATIONS AND FUTURE RESEARCH

The survey study has several limitations that we plan to address in future
work. First, as a limitation of surveys in general, the survey collected second-
hand data provided by parents of children with DS. Therefore, the survey does
not allow us to determine the children’s abilities, but rather the parents’ per-
ception of their children’s abilities. The quality and validity of the data re-
ported are affected by the parents’ understanding and knowledge regarding
computers. In order to collect substantial first-hand data directly from chil-
dren with DS, surveys can be developed targeting older children who can un-
derstand and respond to the survey questions. Parents’ assistance may still be
needed to help the children answer the survey. Future research projects could
also involve observing children with DS using computers in their natural set-
ting, to record problems that they have related to usability.
13: 34 · J. Feng et al.
Second, the survey only targeted children with DS who are currently us-
ing computers. A key population that is not included consists of children with
DS who are not using computers. Information on children who are not using
computers will allow us to make comparisons between the two groups of chil-
dren and identify the critical factors that encourage or hinder a child with DS
from adopting computer-related technology. We are planning to develop a sur-
vey that specifically focuses on children with DS who are not using computers.
The survey will be distributed mainly through DS community newsletters and
postal mailings.
Third, we acknowledge that the categorization of specific items in Figure 1
is worth further examination. The categorization is only used for summariz-
ing the survey results. It is not intended to be interpreted as an established
construct or model to explain the observed difficulties. The boundary between
different categories can be quite fuzzy. For instance, we currently group typing
difficulties under physical limitations. However, typing involves the collabo-
ration of all three sets of human capabilities. The existing categorization is
not the only way to approach this problem and modifications can be made to
improve and clarify the categorization.
11. CONCLUSION
The survey provides, for the first time, a constellation of the difficulties that
children with DS experience when they use computers. Better understand-
ing of the difficulties that these children encounter is the first step to explain
and address these problems. In addition, interesting patterns emerge from
the results regarding the impact of age on different types of difficulty. These
patterns suggest the combined effect of the children’s evolving abilities and
needs as they grow older. The survey also provides insights on the needed ar-
eas for research and helps develop appropriate research hypotheses for future
controlled empirical studies. Some of the identified issues overlap with neu-
rotypical children and children with other types of developmental disabilities,
but the overall picture of computer usage by children with DS is unique and
needs further investigation. Due to the descriptive nature of the data collected
through survey studies, the findings of this survey need to be verified through
more structured, hypothesis-driven empirical studies that allow prescriptive
judgments.
APPENDICES
Appendix A. Survey Questionnaire

Note: For questions with the same choices, only choices in the first question
were included in order to save space.
SECTION 1: GENERAL COMPUTER USAGE
Please answer the following questions based on your child’s computer use.
Both laptop and desktop computers qualify.
1. What are your child’s objectives when using the computer? (Check as many
as appropriate)
Learning Fun Communication
Other (Please specify)
2. How often does your child use word processing applications (e.g., Microsoft
Word)?
Very often Often Sometimes Seldom Never
3. How often does your child use presentation applications (e.g., Microsoft
PowerPoint)?
4. How often does your child use E-mail applications?
5. How often does your child use Instant Messaging?
6. How often does your child use the Web/Internet?
7. How often does your child use educational software?
8. How often does your child use computer applications for videos (e.g., movie
clips, news videos)?
9. How often does your child use computer games?
10. How often does your child use online chatting?
11. If your child visits online chat rooms, which chat room(s) does he/she visit
frequently, and how often (e.g. daily or weekly)?
12. How do you think the activities such as those in Questions 2-10 would help
in your child’s daily life at school?
in your child’s daily life at home?
in your child’s interaction with his/her friends?
in your child’s future?
16. Approximately how many hours per week does your child use a computer
at school?
17. Approximately how many hours per week does your child use a computer
at home?
18. Approximately how many hours per week does your child use the Inter-
net/Web? (combined school and home)?
19. Does your child typically use the computer anywhere aside from school
and home (such as friends’ houses or libraries)? If so, where?
20. How often does your child visit educational websites?
21. How often does your child visit news websites?
22. How often does your child visit entertaining cartoon websites (e.g.,
www.cartoons.com)?
23. How often does your child visit entertaining pictures websites (e.g.,
www.squiglysplayhouse.com)?
24. How often does your child visit entertaining comics websites (e.g.,
www.comics.com)?
13: 36 · J. Feng et al.
25. How often does your child visit entertaining games websites (e.g.,
www.games.com)?
26. How often does your child visit personal homepages?
27. Does your child enjoy using computers alone, or working together on the
computer with other people (including you!), or both?
Alone With other People Both
(mark as many as apply)
Father
Mother
Older/Younger Brother/Sister
Other Family Member
Mentor
Other People (Please Specify):
Comments (if any):

28. Do you encourage your child to use the computer?
1 2 3 4 5 6 7 8 9
Strongly discourage Neutral Strongly Encourage
29. What are the common difficulties your child has, if any, using the com-
puter? (Please type as much as you’d like)
30. What potential solutions, if any, can you suggest to the problems your child
has or may have using the computer? (Please type as much as you’d like)
31. Please provide any other comments regarding your child’s general com-
puter usage. (If any)
SECTION 2: INTERACTION TECHNIQUES
1. Please mark those computer input devices that your child uses (Mark as
many as appropriate)
Keyboard Mouse Joystick
Stylus Touch screen Touchpad
Track ball Keypad Speech
Keyguard (plate placed over the keyboard that allows users to not
accidentally press keys other than the intended key)
Other (please specify)
2. If your child uses a keyboard, which of the following best describes the way
he/she types?
Type using all fingers of both hands
Type using one hand (two or more fingers involved)
Type using two index fingers
Type using one index finger
3. Please mark the output devices that your child uses (Mark as many as ap-
propriate)
Monitor Printer Synthesized

Non-speech audio Haptic (e.g., Speech output
Mouse vibration) Tactile
4. Is your child bothered by unexpected sounds made by the computer (e.g.,
from pop-ups, loud bleeps, etc.) (check one)
Yes To some extent No
Comments (if any):
5. Does your child like animations?

6. Does your child use the printer?
7. Please provide any other comments regarding the interaction techniques
that your child uses. (if any)
SECTION 3: USAGE OF PERSONAL ELECTRONICS

1. Which of the following does your child use? (check as many as
appropriate)
Cell phone Digital watch Calculator
Game System Portable game iPod Other portable
(Xbox, PS2 player (PSP, music player
or GameCube)? Game Boy, etc.)?
Augmentative Other (please specify)
communication
device (e.g.,
Alpha Talker,
BIGMack,
BlackHawk)
2. Is there anything distinguishable or noticeable about his/her usage of

general electronic devices, positive and/or negative?
SECTION 4: DEMOGRAPHIC AND BACKGROUND INFORMATION

The remaining questions are used to help identify varying trends in re-
sponses for different groups of children. Please remember that your responses
will be completely confidential and anonymous.
1. Gender of child: Male Female
2. Age of child (to the nearest year):
3. Number of sibling(s):
4. Age of sibling(s):
5. Highest educational degree obtained by you or your spouse: (check one)
High School Associate Bachelors Masters Doctoral(PhD,
JD, MD, etc.)
6. What is the etiology for your child’s Down syndrome?
Trisomy 21 Mosaic Translocation
13: 38 · J. Feng et al.
7. At approximately what age did your child start using computers?

8. How did your child first learn about computers? (please check only one)
At school From friends From you or other parent From
sibling(s) Other (Please Specify)
9. What school grade is your child currently attending?
10. What is your child’s ethnicity?
Black White Latino Asian Native Americans Other
11. Does your child currently attend a regular or a special education school?
Regular School Special Education School Other
Doesn’t attend school currently
12. If your child attends a regular school, is your child primarily included
in regular education classes, or only in special education self-contained
classes?
Mainstreamed Special education classes
13. How many people currently live in your household (please type a number)?
14. How many computers are there in your household currently (please type a
number)?
15. Where does your child have access to computers? (check as many as appro-
priate)
Home School Community
Library Clinic
16. If there are specific software packages and applications that your child
uses successfully, please let us know what they are.
Appendix B. 86 Coding Items Used in Content Analysis

The Mapping column indicates the nodes in the summary tree that the specific
coding item is mapped to. The mapping column is left blank when the specific
coding item serves as one node in the summary tree.
Code Description Mapping to summary tree

1 ALK Alphabetic keyboard Typing
2 ATT View attachments
3 BK Bigger key keyboard Typing
4 CCK Color coded keys Typing
5 CCL Establish connection between computer Understanding
function and real life concept and activity
6 CF Computer freezing
7 COG Cognitive difficulty
8 CS Clear sign to indicate waiting time Lack of patience
or time to start
9 DC Dual control (children do not like parents Security/Privacy
help/supervision over the shoulder)
10 DE Dated equipment Not included
11 DIS Distribution of software/Software available Software
at regular stores
12 EIF Excessive information

13 ES Eye strain Perceptual
14 ESG Educational software/game useful Software
15 EU Excessive usage of internet Usage pattern
16 FAV Use favorites to navigate to sites Navigation
17 FAW Find appropriate words Writing/Communication
18 FMS Fine motor skill limitation Physical-General
19 FR Frustration
20 FS More focused software that teach specific skills Software
21 FTK Function keys Typing
22 HEC Hand eye coordination Physical-General
23 HI Hearing impairments Perceptual
24 H&P Hunt and peck Typing
25 ICON Set up icons for navigation (Web site URL) Navigation
26 IE Initial encounter Understanding
27 INC Inconsistency in content and design Software
28 IS Information search Design flaws
29 KM Keyboard modification Typing
30 LAN Language difficulty
31 LET Low error tolerance
32 LIT Larger icon/target/font Mouse
33 LOI Lost interest in computers Usage pattern
34 LP Lack of patience
35 LSR Limit number of search returns Design flaws
36 LT Long loading/response time Lack of patience
37 MCD Mouse click difficult Mouse
38 MD Mouse difficulty
39 ML Memory limit
40 MM Multimodal solutions Typing
41 MOM Modified mouse Mouse
42 NAV Navigation difficulty
43 OCTB One click two button combined mouse Mouse
44 PCT Perception of computer as a useful tool Understanding
45 PD Personalized design Cognitive - general
46 PI Passive interaction Usage pattern
47 PIN Proper instruction Reading/Design flaws
48 PP Pop-ups
49 PS Phonic spelling Typing
50 PW Remembering/typing password Security/Privacy
51 RCON Engage in real conversation
52 RD Reading difficulty
53 RLE Find software/website/textbook of right level Software
54 SAS Short attention span Cognitive - General
55 SC Spell check Typing/Spelling
56 SCLA Simple computer/operating system with limited Software/Excessive
applications information
57 SH Small hand, short finger Physical-General
58 SK Simplified keyboard Typing
59 SLM Slower mouse Mouse
60 SM Smaller mouse Mouse
61 SMR Small mouse selection range Mouse
62 SPD Spelling difficulty/spelling errors
63 SR Speech recognition Typing/Spelling
64 SS Speech synthesis Reading
13: 40 · J. Feng et al.
65 SWRL A list of rated software for kids with DS Software

66 S&P Security and privacy concern
67 TAM Too advanced materials
68 TAS Training at school Educational
69 TC Time constraint
70 TD Typing difficulty
71 TMW Too many windows
72 TOUCH Touchscreen Typing
73 TS Trouble shooting
74 TSF Tracking and supervision functions Security/Privacy
75 TU Tutorials Software
76 UIN Understanding instructions Understanding
77 UMENU Understanding menus Understanding
78 UN Understanding, slow response by the child Understanding
79 URL Can’t enter url due to typing/spelling difficulty Typing/Spelling
80 VD Visual design Understanding
81 VI Visual impairments Perceptual
82 VP Victim of online predators Security/Privacy
83 WCD Writing/communication difficulty
84 WB Word bank Typing/Spelling
85 WP Writing program with spelling check and filling Typing/Spelling
in letters functions
86 WWW Answer who, where, why questions
ACKNOWLEDGMENTS
The authors would like to thank all the parents who responded to the survey.
The authors also like to thank the editor and the reviewers for their thor-
ough and constructive comments that helped tremendously when revising the
article.
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Received May 2009; revised September 2009; accepted October 2009

Computer Usage by Children With Down Syndrome: Challenges and Future Research

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Computer Usage by Children with Down

Syndrome: Challenges and Future Research 13

ACM Reference Format:

2.1 Causes and Characteristics of Down Syndrome

2.2 Computer Usage as Related to Individuals with Down Syndrome

3.1 Survey Design

3.2 Data Collection

3.3 Data Collected and Content Analysis Procedure

using passwords” may be attributed to both cognitive limitations that make it

Fig. 1. Summary of difficulties experienced by children with DS (numbers in parentheses repre-

4.1 Language Difficulties

4.1.2 Writing and Communication Difficulties. Most children with DS

4.2.1 Navigation. Navigation is reported to be a big challenge for children

“He cannot resolve a problem if he opens a window that he did not

4.2.4 Design Flaws. Some frustrations can be attributed to design flaws.

Another commonly made design flaw is inconsistency. Parents reported that

“Mostly she has trouble adapting between different control systems.

4.3 General Cognitive Difficulties

“[His difficulty is] probably understanding the connection to the out-

In addition to difficulties in understanding concepts, children with DS also

“Many educational games are based on speed of response, and he

“Her comprehension skill level is below an average child her age.

5.1 Typing Difficulty

5.2 Mouse Difficulty

and modified with the use of computers. Professionals should be

7.2 Security and Privacy

is not confident with his spelling so often he needs me to type his

“. . . She has to get someone to do the password for her, so we know

8. IMPACT OF AGE ON COMPUTER USAGE

educational programs and computer applications fail to establish a concrete

9.1 Implications of Unique Characteristics of DS for Design

example, a substantial number of parents proposed the use of speech recog-

9.1.3 Impact of Comparatively Strong Social Skills. Children with DS ex-

9.2 Implications for General Design and Research Approach

9.3 Implications for Future Research

9.3.1 Input Solutions. Further research is needed to help children with

When a speech-based technique is evaluated, the comparison should not

9.3.2 Solutions for Information Presentation. Parents frequently sug-

9.3.4 Security and Privacy Protection. Viruses, worms, phishing attacks,

the mnemonic password dictionary becomes more comprehensive [Kuo et al.

10. LIMITATIONS AND FUTURE RESEARCH

Appendix A. Survey Questionnaire

SECTION 1: GENERAL COMPUTER USAGE

Comments (if any):

SECTION 2: INTERACTION TECHNIQUES

Monitor Printer Synthesized

5. Does your child like animations?

SECTION 3: USAGE OF PERSONAL ELECTRONICS

2. Is there anything distinguishable or noticeable about his/her usage of

SECTION 4: DEMOGRAPHIC AND BACKGROUND INFORMATION

7. At approximately what age did your child start using computers?

Appendix B. 86 Coding Items Used in Content Analysis

Code Description Mapping to summary tree

12 EIF Excessive information

65 SWRL A list of rated software for kids with DS Software

Received May 2009; revised September 2009; accepted October 2009

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