Considering accessibility for people with cognitive disabilities and differences
In celebration of Global Accessibility Awareness Day 2022, I wrote the following article for my employer, who is celebrating GAAD with a day-long series of events including workshops about accessibility topics, panels about disability awareness, and articles such as this one, introducing topics about digital accessibility.
The term COGA stands for cognitive accessibility, which is an area of digital accessibility that supports the removal of barriers from digital experiences for people with cognitive disabilities and differences. People with cognitive disabilities can have issues with attention, memory, learning, and executive functions. Technologists can and should be considering people with cognitive disabilities and differences from the beginning of the design and development lifecycle process.
Here is a content table for this article if you wish to scroll directly to a particular section:
- Visible and Invisible Disabilities
- Cognitive and Learning Disabilities
- Challenges with Cognitive Skills
- Cognitive Accessibility in Digital Experiences
- WCAG 2.1 and Cognitive Accessibility
- A Note About Long Covid
- Additional Resources
Visible and Invisible Disabilities
According to the Americans with Disabilities Act of 1990 (ADA) a person with a disability is defined as someone who has a physical or mental impairment that substantially limits one or more major life activities, has a record of such an impairment, or is regarded as having such an impairment. One in four people in the United States has a disability.
When thinking about the term “disability,” many people quickly visualize someone using a wheelchair, relying on a service animal, or communicating with sign language. These varieties of disabilities can be classified as visible disabilities, which means that there is a visible or apparent indicator that the person is disabled. Visible indicators can include assistive devices, a communication style, or a particular physical feature.
Invisible disabilities are less obvious to able-bodied people. Invisible disabilities can include a wide range of challenges that are typically a result of neurological disabilities. Some examples of invisible disabilities include chronic pain due to Fibromyalgia, brain injury, chronic illnesses such as diabetes and sleep disorders, and cognitive and learning disabilities such as Dyslexia or Dyscalculia.
Why make a distinction between visible and invisible disabilities?
It has to do with the problem of public perception. While having a visible disability can prove frustrating due to the general public immediately perceiving a person as incapable, having an invisible disability can present its own set of problems. Without the visual indicators, individuals might be perceived as being “normal.” The Invisible Disabilities Association argues that
“People often judge others by what they see and conclude a person can or cannot do something by the way they look. This attitude can be equally frustrating for those who may appear unable but are perfectly capable, as well as those who seem able, but are not.”
Assumptions about a person’s abilities due to the presence of visible indicators can be wrong and damaging. These types of assumptions only serve to support the United Nation’s Convention on the Rights of People with Disabilities understanding that
“Disability results from the interaction between persons with impairments and attitudinal and environmental barriers that hinder their full and effective participation in society on an equal basis with others.”
Cognitive and Learning Disabilities
According to the World Health Organization, more than 1 billion people — 15% of the world’s population — experience some form of disability. These numbers are rising due to increasing chronic illness and aging populations. Cognitive is the largest category of disability across the globe and it also encompasses the most wide-ranging of experiences. Examples of people with cognitive disabilities could be a person with brain injury struggling to use language to communicate, or a person with ADHD who gets extremely frustrated filling out a web form, or a person with Long Covid having difficulty with concentration.
For many, particularly medical professionals and researchers, cognitive disabilities are understood through the lens of the medical model. This model centers the perspectives of the treating physicians, who typically assume that a person with a cognitive disability has a disorder or defect that needs medical treatment to improve their quality of life. That the individual needs to be treated because they deviate in some way from “normal” cognitive development. The following is a brief list of a few of the most well-known cognitive and learning disabilities described from the medical model perspective:
Aphasia
Aphasia is a condition that affects a person’s ability to communicate. It can affect speech, writing, and the understanding of both spoken and written language. Aphasia can result from a stroke or head injury. Temporary aphasia can occur during a migraine, seizure, concussion, or TIA (transient ischemic attack). This condition can be frustrating to a person as it is not reflective of their intellectual ability. It is only an indicator of their difficulties in understanding language. Famous actor Bruce Willis was recently diagnosed with Aphasia.
Autism
Autism, or the medical diagnosis autism spectrum disorder (ASD), “refers to a broad range of conditions characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication. According to the Centers for Disease Control, autism affects an estimated 1 in 44 children in the United States today.” Stuart Duncan, an autism advocate whose son is on the spectrum, tweeted “Autism is one word attempting to describe millions of different stories.” Dr. Stephen Shore, another autism advocate, says “If you’ve met one person with autism, you’ve met one person with autism.”
ADHD and Attention Deficit Disorder
Attention Deficit Disorder (ADD) is a term often used by non-medical people to describe “a neurological condition with symptoms of inattention, distractibility, and poor working memory.” However, since 1994, doctors have been using the term ADHD or attention deficit hyperactivity disorder, which is an actual neurological or psychological disorder. “ADD” is no longer a diagnosis and is considered by the medical community to be an outdated term.
There are two types of ADHD: Predominantly Inattentive Type and Predominantly Hyperactive Type. People diagnosed with Predominantly Inattentive Type ADHD have what are considered the classic symptoms of “ADD,” which includes poor working memory, inattention, distractibility, and poor executive function. On the other hand, adults diagnosed with Predominantly Hyperactive Type ADHD might be talkative, have nervous energy, be fidgety, or struggle to wait their turn.
The CDC estimates that more than 6.1 million children in the United States (9.4 percent) between ages 2 to 17 have been diagnosed with attention deficit hyperactivity disorder. Between 30% and 70% of children with ADHD continue to have symptoms into adulthood. Some of the challenges faced by adults with ADHD include poor organizational skills, procrastination, chronic boredom, trouble concentrating while reading, and low self-esteem. Olympic medalist Simon Biles advocates for those diagnosed with ADHD. Regarding her own diagnosis she argues that “Having ADHD, and taking medicine for it is nothing to be ashamed of and nothing that I’m afraid to let people know.”
Dyslexia
Dyslexia is a language-based learning disability. People diagnosed with dyslexia often have difficulties with accurate letter and word recognition, poor spelling, and decoding abilities. This makes phonics-based reading instruction, the primary approach to literacy in primary schools, a difficult path for people with dyslexia. Number sequencing can also be problematic pain point. For example, a person working retail might tell a customer a product is $49 when they mean $94.
People with dyslexia can also have issues with spoken language, specifically being able to clearly express themselves or to really understand others speaking to them. One area of this struggle concerns directions and direction sequencing. For example, someone may experience left-right confusion by telling a driver to “turn left” when they meant to tell them to “turn right.”
Dyscalculia
Dyscalculia is a math learning disability that occurs in 3% — 6% of the population. It affects an individual’s ability to work with numbers and do basic arithmetic. People with dyscalculia may have limited numbers sense, have poor memorization of math facts, and can easily make mistakes doing calculations. Adults with dyscalculia may be slow to perform calculations, have difficulty counting backwards, a poor sense of numbers and estimation, and have high levels of mathematics anxiety.
It is important to recognize that many people who present with these various cognitive disabilities do not perceive themselves as having defects that need to be treated. This is emphasized by many advocates within the autistic community. Jac den Houting, research psychologist and autistic advocate, centers this philosophy in her TedX talk “Why Everything You Know About Autism Is Wrong.” She argues “In the medical model we’re taught to believe that there’s a correct way to develop neurologically. That there’s a right way for our brains to work, the “normal” way, and that any other way of developing is wrong and needs to be treated and fixed.” However, she points out an alternative framework for understanding her own diagnoses of autism: the neurodiversity paradigm.
According to den Houting, the neurodiversity paradigm “describes autism as part of the range of natural variation in human neurological development. At its very simplest, autism is a different way of thinking. Just like biodiversity helps to create a healthy and physical sustainable environment, neurodiversity can help to create a healthy and sustainable cognitive environment.” She goes on to argue that the neurodiversity paradigm supports the idea that
“There are no right and wrong brains. All forms of neurological development are equally valid and equally valuable. And regardless of what type of brain you’ve got, all people are entitled to full and equal human rights and to be treated with dignity and respect.”
For technologists this sentiment should be the banner under which we design and develop our digital experiences. We must understand the accessibility barriers and usability challenges faced by people with diverse cognitive abilities, and use our craft and our awareness to create products that are successfully used with ease and clarity.
Challenges with Cognitive Skills
Rain Michaels, in her axe-Con presentation “Making Content Usable for People with Cognitive and Learning Disabilities,” highlights the fact that people with cognitive disabilities and differences may have unique cognitive challenges that extend beyond their medical diagnoses. Michaels states “There’s no real universal language to categorize cognitive disabilities…There’s not necessarily a one-to-one mapping between a disability diagnosis and the actual functional needs that somebody may have.”
What functional needs do people have in order to function in their daily routines? Michaels identifies these functional needs in relation to cognitive skill categories such as attention, language and literacy, learning, memory, and executive function. She describes each functional skill category as follows:
Attention
Attention is the ability to focus and stay focused on something specific, or the ability to redirect that focus to something else.
Language and Literacy
Language and literacy is a big category that revolves around visual processing, decoding characters or illustrations, being able to understand hidden and implied meanings within a text, or writing fluently.
Learning
Learning is typically defined as an individual’s ability to take in and maintain information. It’s also looked at in the context of skills. For example, reading disabilities and people with difficulty with numerical processing might be considered in the learning space.
Memory
Memory is often thought of in terms of long-term and short-term memory. Long-term memory deals with learning and short-term memory has a lot to do with executive functioning. However, memory can also deal with a person’s reliance on visual or spacial memory, as well as auditory memory.
Executive Function
Executive function is an individual’s ability to plan, to organize, and to have the emotional control or regulation that they need in order to navigate a specific situation the way that they intend to.
It’s important to highlight an understanding that cognitive disabilities can be permanent, temporary, or situational. A person diagnosed with Dyscalculia or Dyslexia would have a permanent cognitive disability. A person with a concussion or someone taking certain types of medications would experience temporary cognitive impairment, while a distracted driver might have a situational cognitive impairment.
Cognitive Accessibility in Digital Experiences
It is essential that technologists consider cognitive disabilities and differences when building products and services in digital spaces. Product teams must consider design patterns that best support people with cognitive disabilities, development practices that support integration of assistive technologies, as well as usability guidelines to make digital content accessible and usable.
There are many accessibility concerns that affect people with cognitive disabilities. These include issues about design, context, structure, language, and usability. Each of these issues can affect a person’s cognitive load, defined here as the amount of working memory or short-term memory someone is using while interacting with a website or application. When a person’s cognitive load is overwhelmed it can result in their being fatigued and unable to successfully interact with a digital experience.
In order to support the digital accessibility needs of people with cognitive disabilities, the W3C-WAI Cognitive Accessibility (COGA) Task Force is working on an important resource Making Content Usable for People with Cognitive and Learning Disabilities. This resource explores the following topics:
- people with cognitive and learning disabilities,
- aims and objectives for usable content,
- design patterns (ways) to make content usable,
- including users in design and testing activities, and
- personas (examples) and user needs.
The document maps out nine written objectives for technologists to consider when building an accessible digital product that makes content welcoming and usable for people with cognitive disabilities. The objectives include:
1. Help users understand what things are and how to use them.
Content needs to have a clear purpose so that a user can know whether they are in the right place and so that they can determine what they need to do. Users also need to know which controls are available to them and how to operate them. New and creative interaction patterns are always a detriment to users with cognitive disabilities. Tolu Adegbite, in her presentation “Designing for Cognitive Disabilities,” argues that designers should be
“Using common patterns in existing mental models is a great way of reducing cognitive load. There is no need to reinvent the wheel…As much as possible following existing patterns is really helpful for people with cognitive disabilities.”
Make buttons act like buttons, make links act like links, and don’t confuse the two. Finally, recognizable, personalizable, and commonly-used symbols can also be used to clarify the meaning of content.
2. Help users find what they need.
Users need to be able to find all critical information within a reasonable amount of time. They need to be able to search to find things. And they have to be able to clearly navigate to locate what they are searching for in a page or application. Rain Michaels argues that while findability, searchability, and clear navigation are all tenets of good design, they are also vitally important for users facing accessibility barriers. She reminds us that “When somebody has an accessibility barrier, the difficulty of bad design, or even sort of seemingly good but not quite good enough design, can have a 10 times negative impact on the individual that really becomes a blocker and makes it impossible for them to use the system.”
3. Use clear content (text, images, and media).
Users rely on language that is clear and easy to understand so that content is understandable when read in context. There should be a good visual layout that makes use of whitespace, background and foreground contrast, and good HTML heading semantics so that users can make appropriate connections about content.
Images should also be clear and videos easy to understand. Tolu Adegbite shares designers may avoid visuals in video because are concerned about the strategies for making that content accessible. She argues that there is a misguided belief that by avoiding images and video content is made more accessible. She states
“Having videos and visuals is a great way to augment and support your content, but also support people with like a wide variety of like learning needs and people who process information differently. You just have to remember that when you use visuals and videos to provide a transcript and close captions in the case of video or alternative text attributes in the case of visuals. By no means, does that mean that you need to stay away from them. They can actually be a really helpful tool for reducing cognitive load for people.”
4. Help users avoid mistakes and know how to correct them.
User mistakes can be avoided by employing good design and development patterns. For example, designers should incorporate labels, helper text, and instructions for error prevention in forms. Likewise, developers can provide autocomplete assistance to ensure successful and accurate input completion. If mistakes are made, users should be able to quickly and easily undo their error. Also, inline errors with clear instructions should be provided to help the user easily fix the problem.
The article “10 Usability Heuristics for User Interface Design” emphasizes this same sentiment by pointing out that
“Users often perform actions by mistake. They need a clearly marked “emergency exit” to leave the unwanted action without having to go through an extended process. When it’s easy for people to back out of a process or undo an action, it fosters a sense of freedom and confidence. Exits allow users to remain in control of the system and avoid getting stuck and feeling frustrated.”
Users with disabilities need well-designed error flows to keep them on track and help them from preventing mistakes, or easily correcting them when they occur.
5. Help users focus.
Users with cognitive disabilities can become easily distracted. Limit interruptions that might distract from a user focusing on completing their task. Distracting interruptions can be things such as popup advertisements, automatically playing video, sounds, and dynamic carousel content. Also, help users navigate a workflow by helping them understand the steps needed to complete a task or workflow, as well as the progress and status of where they are as they complete these required steps. Keep the process short and avoid unnecessary steps.
Remember, cognitive fatigue in digital spaces is very real. Reducing clutter and distractions helps users remain focused and maintain enough energy to successfully interact with a digital experience. Cognitive accessibility advocate Jennie Delisi describes cognitive fatigue through the use of “spoon theory,” a metaphor created by Christine Miserandino, whereby individual spoons are symbolized as having energy. She explains that
“This energy is a precious a limited resource and is more difficult to replenish that it is to use. Throughout a digital experience there can be energy stealers, distractions, and triggers and frustration. These may have an even larger impact on people with cognitive disabilities. The energy it takes to complete a process within a digital space can be its own type of digital barrier.”
(Shell Little, in her presentation , has an excellent explanation of spoon theory. I have the video presentation linked here to start at the section about spoon theory.)
6. Ensure processes do not rely on memory.
Memory barriers represent a significant accessibility issue for people with cognitive disabilities. In regards to this concern there are several strategies to make a product more usable:
- help users remember what their last steps without forcing them to use the previous button.
- allow users to cut, copy, and paste content so that users are forced to rely on memorization of information.
- provide simple-to-navigate voice-menu systems with limited options so a user doesn’t get overwhelmed.
- ensure accessible authentication by making sure users don’t have to do things like perform calculations, copy content, or recognize distorted characters. In addition, developers can integrate an auto-suggest feature so users don’t have to unnecessarily memorize a verification code, which can be a drain on cognitive load.
7. Provide help and support.
If a user is having problems with any aspect of a website or application, make it easy for users to provide feedback and get actual human help and support. Also, provide different ways to understand content such as providing summaries of long documents.
8. Support adaptation and personalization.
Users with cognitive disabilities often use tools and products that support adaption and personalization. For example, add-ons and extensions such as spell checkers and passwords support might be used as assistive technology. It’s best to not disable these particular accessible strategies. In the #id24 presentation, “Your Brain Is Welcome Here,” Glenda Sims states
“In the area of cognitive accessibility personalization is an absolute essential. If we’re going to say that we value differences, we need to actually support the needs of individuals. We need to let people select what works for them.”
In short, support the adaption, personalization, and simplification of content to reduce the stress on an individual’s cognitive load.
(If you prefer a video walkthrough of the meaning and purpose of these objectives please watch Rain Michaels during her recent axe-Con presentation. I have the video linked here to start at this part of her presentation.)
WCAG 2.1 and Cognitive Accessibility
The Web Content Accessibility Guidelines issued by the W3C Web Accessibility Initiative (WAI) believes websites and digital products should be Perceivable, Operable, Understandable, and Robust. Several of these guidelines address cognitive accessibility including:
Guideline 1.3 Adaptable
Create content that can be presented in different ways (for example simpler layout) without losing information or structure.
Guideline 2.2 Enough Time
Provide users enough time to read and use content.
Guideline 2.4 Navigable
Provide ways to help users navigate, find content, and determine where they are.
Guideline 3.1 Readable
Make text content readable and understandable.
Guideline 3.2 Predictable
Make Web pages appear and operate in predictable ways.
Guideline 3.3 Input Assistance
Help users avoid and correct mistakes.
A Note About Long Covid
According to the Center for Disease Control (CDC), “some people who have been infected with the virus that causes COVID-19 can experience long-term effects from their infection, known as post-COVID conditions (PCC) or long COVID.” Those who experience Long Covid typically report symptoms including, but not limited to: tiredness or fatigue that interferes with daily life, symptoms that get worse after physical or mental effort, difficulty thinking or concentrating (“brain fog”), lightheadedness, headache, and sleep problems. A study by the Journal of the American Medical Association found that 87% of patients had at least one symptom two months after their original diagnosis.
With an increasing number of people suffering from Long Covid, technologists must respond by inclusively researching, designing, and developing for those with cognitive disabilities. Gareth Williams argues that the first step for designers and researchers should be
“…recognising and accepting that our disability and neurodivergent communities are expanding. Not everyone with Long-COVID will identify as having a disability or being neurodivergent, but their lived experiences and barriers will be ones that we are familiar with.”
Williams also believes greater emphasis should be placed on understanding the role of fatigue as an accessibility barrier. He states “Fatigue in itself as an intersection with all existing barrier groups will be a fascinating area of research. Has anyone looked into fatigue for screen reader, switch, keyboard, magnifier or voice control users?”
Ted Drake, director of accessibility at Intuit, argues
“There’s a lack of information about how we can use our roles as accessibility and inclusive design leaders to improve the usability of our products and services for people who have Long COVID and its associated disabilities. Now is the time for us to reevaluate our work to include short term memory loss, anxiety, loss of focus, readability, and alternative documentation formats.”
Is Long COVID actually considered a disability? The answer is yes.
In the document “Guidance on “Long COVID” as a Disability Under the ADA, Section 504, and Section 1557," released by the US Department of Health and Human services and the US Department of Justice, Long Covid is considered a disability under Titles II (state and local government) and III (public accommodations) of the Americans with Disabilities Act (ADA), Section 504 of the Rehabilitation Act of 1973, and Section 1557 of the Patient Protection and Affordable Care Act.
The guidance argues that Long COVID is a form of physical or mental impairment and that it can substantially limit major life activities. People with Long COVID are afforded the protections from discrimination as any other person with a disability under the ADA. “This may mean that businesses or state or local governments will sometimes need to make changes to the way that they operate to accommodate a person’s long COVID-related limitations.” However, it is not always considered to be a disability, and the guidance suggests that people with Long COVID will need individualized assessment in order to determine their status.
Additional Resources
Video Presentations
- Designing for Cognitive Disabilities, Tolu Adegbite
- Making Content Usable for People with Cognitive and Learning Disabilities, Rain Michaels
- Your Brain is Welcome Here, Glenda Sims and Jennie Delisi
- Why everything you know about autism is wrong, Jac den Houting
- Fix Your Error Flows, or Send Me More Spoons, Shell Little
Articles
- “An Introductory Guide to Understanding Cognitive Disabilities,” Glenda Sims and Jennie Delisi
- “10 Usability Heuristics for User Interface Design,” Jakob Nielsen
- “Long COVID, Brain Fog, and Inclusive Design Resources,” Ted Drake
- “Long COVID or Post-COVID Conditions”, CDC
- “ ‘Long Covid’: Why are some people not recovering?,” BBC — James Gallagher
- “How will Long-Covid Change the UX Accessibility Landscape?,” Gareth Williams
- “The Spoon Theory,”Christine Miserandino
- “COVID-19 and the Definition of “Disability” Under the ADA/Rehabilitation Act”
- “Designing for Cognitive Disabilities,” Tolu Adegbite
- MDN Cognitive Accessibility
- “Welcome, WCAG 2.1! The Web Content Accessibility Guidelines get an update.,” Becky Gibson
- “What is aphasia? Bruce Willis is ‘stepping away’ from acting after diagnosis,” Erik Ortiz and Tim Fitzsimons
- “Bravo, Simone Biles, for taking a stand against ADHD stigma,” ESPN
