The post below is offered by Drs. Connie Kasari and Ann Kaiser along with team members, Drs. Charlotte Mucchetti, Stephanie Shire from UCLA and Dr. Courtney Wright from Vanderbilt University.
iPads have created quite a buzz among families raising a child with autism. For nearly everyone today, the latest technology has made connecting to social media a highly preferred activity, and children with autism are no different. Based on a unique study funded by Autism Speaks (High Risk, High Impact Study: Characterizing Cognition for Nonverbal Individuals with Autism Spectrum Disorders (CCNIA)), the research teams at UCLA, Vanderbilt and Kennedy Krieger Institute (Connie Kasari, Ann Kaiser and Rebecca Landa, Principal Investigators) tested a developmentally-based, behavioral intervention for teaching spoken language using speech generating devices (SGD), including iPads, in addition to spoken language.
This study of 62 children seen over a nine-month period found that using the SGD together with spoken language yielded significantly greater improvement in spoken language in comparison to the same intervention without access to the SGD. These data and our experiences using SGDs within a behavioral intervention may allay parents’ fears about using the iPad for teaching language, and provide some direction for how to best encourage children to use iPads and spoken language.
Below we offer some helpful tips in using the iPad for teaching social communication, particularly among children who are not yet fluent communicators.
Common questions asked by parents in using the iPad with their children.
Does this mean we have given up on spoken language? If we use the iPad will my child get dependent on the iPad and give up on talking?
We really have limited evidence that children give up on talking or become dependent when they use Speech Generating Devices (SGD) to communicate. If anything, the SGD actually HELPS children to increase their use of words. In our study, children who were exposed to the SGD within the context of a play based intervention (Joint Attention, Symbolic Play, Engagement and Regulation; Kasari, et al, 2008) with explicit spoken language targets (Enhanced Milieu Teaching; Kaiser, 1993) that were spoken by the therapist and simultaneously modeled the SGD helped children to develop more spontaneous use of spoken language. The behavioral intervention and the specific focus on social communication was important, however, to the ability of children to connect words and actions in natural contexts. Importantly, the words children used were not just for requesting something, but also included comments on what they were doing or thinking.
Many children who learned to use spoken language decreased their use of the SGD/iPad over time because spoken words are quicker to use and more readily available than the SGD/iPad. Other children used the iPad to ‘repair’ when the adult did not understand. For example, if children are not clear in their spoken language, the SGD/iPad can be used to restate what they are saying to make it clear to their social partners.
What types of application programs can help with communication?
The application we used in the study was Proloquo2go. It is a symbol-based voice output communication application that can be programmed for your needs, but it is not free. The main thing to look for in the application is flexibility. In order for your child to learn to use an iPad for communication, the program must be sufficiently flexible to allow you to customize it to fit your child’s skills and needs. A list of iPad applications can be found here and it is continually growing, so stay tuned!
Some suggestions for getting started with setting up your iPad for communication (Be sure to check with your Speech and Language Therapist)
- The type of visual you use should depend on what your child has experience with and understands. Does your child understand that a symbol can represent a real world object? Children may be used to using symbols to make requests at school, and may have some experience with using the Picture Exchange Communication System. These children probably have some symbolic understanding - they know that showing the symbol for "water" is related to getting actual water. A child who has not had any exposure to symbols should probably start out using actual photographs of objects rather than picture symbols - that will help them relate what they see on the iPad screen to the real world objects and actions they represent.
- Visual display – In order to be successful with an iPad communication system, children have to be able to scan through the symbols on the screen and identify the one that they want. Children differ in their visual discrimination abilities and the visual display of the communication program can be set up to match their abilities. Some children can start with a screen that has many symbols on it, and see the difference between symbols that look similar. Other children need to start out with just a few symbols or pictures on the screen (2-4 symbols) and these symbols may need to look very different. This will allow the child to start developing the visual discrimination skills necessary to expand to more complex visual displays. One clue that a child is struggling with a visual display that is too difficult for them is if they touch symbols indiscriminately in order to try to communicate. They understand that touching something on the iPad is necessary for communication, but they haven't yet realized that different symbols have different meanings. For these children, it's important to simplify the visual field so that they can learn to attend to and see the difference between different symbols, and connect them to the objects and actions they're trying to talk about.
How do I get him to use the iPad for communication and not for YouTube?
Indeed, this is a challenge, and one reason we also relied on a dedicated device, such as the Dynavox V for our study that did not have access to wifi. But these devices are expensive. The Dynavox V is more than fourteen times the cost of an iPad and fairly cumbersome to carry around! In our current study with minimally verbal children (ACE Network; Kasari, Kaiser, Lord, Smith, Almirall and Murphy), we are using the iPad exclusively and we lock it so the child cannot access YouTube!
We also caution that the type of intervention used with the iPad matters. Some children will understand right away that the iPad can help them communicate. But most minimally verbal children will need direct instruction to learn. They also need a context in which to communicate. We used an intervention that engaged the child in shared activities with the goal to increase joint engagement, social communication gestures and spoken language.
Below we offer some tips on getting the conversation going…..
- You need to plan playtime to practice communicating with the iPad. If necessary, have one iPad that is used for communication and another for playing games or accessing the internet. Alternatively, use a different cover for the same iPad when you are using it to practice communication. It may also help to have designated times for when the iPad can be used for YouTube and other game applications if your child enjoys those functions.
- When playing with your child, choose a shared activity that your child really enjoys (for example, read a book together, build a structure with Lego blocks, cook something together). Be flexible and change activities if your child loses interest in play and communicating.
- Have your iPad nearby and programmed with icons that are related to your activity. Icons should include some labels (block, truck, bucket) and some verbs or action words (stack, dump, crash, on). Start with a small number of icons (4-6) and add more as your child learns and uses these words.
- As you take your turn, talk about what you are doing. If you are putting a Lego on the structure, you might say ‘block on’, and then press the icons on the iPad for ‘block’ and ‘on!’. The child hears you say it, sees the visuals on the iPad, and hears the iPad also says ‘block on!’.
- Be sure the iPad is where your child can see and hear it, and where he can reach it to communicate. Model communicating using the iPad where your child can see you as you use the device. Consider modeling on the iPad first and keep your arm and finger extended to the device while you model the language verbally so they can see the corresponding icons on the device.
- It is important to vary your language by using different words and matching your words to the toys and actions the child can see. However, we also know that speaking at your child’s language level is important. We use the plus-one rule. If your child usually speaks with one word, then you should imitate his or her word, and add one more. If he says ball, you could say ‘ball rolls’ for example. If he says, ‘want cookie’, you could say, ‘want chocolate cookie!’
- When you model using the iPad, the child will often imitate you. You may not need to prompt him or her to use the iPad. However, some children will need you to help them press the icons on the iPad. You can use “ hand over hand” to activate the iPad together. Follow up by repeating what he says on the iPad and add another word to his statement. If your child is requesting something, be sure you give him the item he requested (the cookie) in addition to expanding what he said.
- It is important to focus on modeling commenting (“big tower,” “we are building”) and creating opportunities for your child to comment in addition to making opportunities for requesting. Most children with autism learn to make requests, but have more difficulty learning to comment. One of our findings from our CCNIA study was that children increased in the number of comments they made, such as, “funny,” “car crashed” and “baby sleep.”
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