Today on the iTunes store, there are around 100 Augmentative and Alternative Communication (AAC) Apps. These are specifically designed to be used by people who have complex communication needs – for people who want to use their iPhone or iPad to communicate face-to-face with others. Many of these AAC Apps are among the highest priced Apps in the App Store – but are they worth the cost? And what do they offer that more traditional speech generating devices don’t?

The answer to those questions depends on a large number of variables – including the App itself, the needs of the user, other communication options available to the user and how the user can physically access the iPad or iPhone. Let’s start by discussing the Apps.

As mentioned earlier there are around 100 AAC Apps currently in the iTunes store. Proloquo2Go, the first AAC App, developed jointly by Samuel Sennott and AssistiveWare, remains one of the best options available. It offers a range of vocabulary, a comprehensive symbol set, Symbolstix, and allows users to string together symbols to speak sentences or phrases. Users can also pull up a keyboard and type what they want to say. Proloquo2Go reflects good practice in AAC and is used by thousands of people worldwide. Numerous articles have been written in newspapers and magazines about how Proloquo2Go has been successful in giving children and adults a voice – while harnessing the “cool” factor of the iPad and iPod touch. An example of a recent article can be found here.

As seen in this article, the iPad (along with Proloquo2Go) has been a game changer for children and adults with autism spectrum disorder (ASD) in particular. So much so that Apple featured the use of the iPad with children with ASD in their launch of the iPad2.

Following on from this success, a number of other AAC Apps have been released upon the world. These vary enormously in quality and price – and some of them fill a different niche to the one carved out by Proloquo2Go. Many of them do not reflect good practice in AAC – and are incredibly overpriced for what they offer. They may not include any symbols, or don’t let the user string together words to create novel sentences. Some of them crash frequently, or have very poor quality speech – despite their comparatively high price tag.

Of course, some of the new Apps are good quality – Predictable, an AAC App released earlier this year, is well designed and well thought out. It is designed for literate end users and offers customisation, control and alternative access options. Similarly, Verbally, another AAC App released only a few weeks ago, is a high quality AAC App that is free of charge to the end user. Unfortunately, though, these high quality Apps tend to be in a minority rather than a majority – definitely a case of user beware! (And to assist potential users, I maintain a regularly updated list of AAC Apps, along with ratings, at http://www.spectronicsinoz.com/article/iphoneipad-apps-for-aac)

Moving on from the Apps, we need to look at the hardware. I am, I must admit, completely addicted to my iPad. I love it. I can understand why many users and families want this cool, elegant and easy to use piece of technology as their speech generating device. And I hope that the ease of use and “cool” factor of this technology is providing many traditional speech generating device manufacturers with ideas for their next generation of devices. I really look forward to seeing what impact this consumer technology has on speech generating devices as a whole.

Just as I can understand why families want this technology, I can also understand why many professionals are worried about the iPad being used as a speech generating device. The volume isn’t sufficient for many situations, the hardware is a lot more fragile than many of the dedicated speech generating devices and the access options for people with physical disabilities are limited. At this stage, if I need to use a head switch or foot switch, I have only very limited control of a small number of Apps on my iPad. For this group of users, a dedicated speech generating device is still the only option which gives complete control and flexibility. As a therapist – I could spend a lot of time trying to “make” this technology work for someone when there is a piece of specifically designed technology that will work straight away and with a range of well designed page sets which only need minimal customisation for the user. Of course – this doesn’t apply to everyone. Some people fly with their iPad from day one – while others are still trying hard to get to the first step a year later. Sometimes, this is because the hardware and/or App are an inappropriate match for the end user. Sometimes, however, it is due to poor setup and support.

And that brings me to my next point – expertise. Because this technology is cool, widely accessed and relatively cheap – suddenly we have a huge turn around in AAC recommendations. Historically, speech generating devices have been recommended primarily by speech pathologists, many of whom have specialised in AAC for years. We know the technologies available and what they can do. Furthermore, once a device has been recommended we can provide support to ensure the best possible outcomes for an individual. This model of expert assessment and recommendation, however, is now being consistently bypassed when recommending AAC Apps and iPads or iPhones. People with little or no knowledge of AAC are suggesting this option as a solution – the best App for the individual isn’t necessarily being considered and the setup of the communication pages for best outcomes isn’t always happening. In addition, once an individual or family receives the App and hardware, no expertise is provided to ensure good outcomes for the user. Modelling the user’s AAC pages frequently doesn’t happen – and in many cases the vocabulary design does not reflect good practice in AAC. As a result, nearly every day we hear stories of people who received an iPad and an AAC App that they haven’t been able to use – or of a person who received an iPad for AAC but only uses it for game playing or for watching videos.

This technology is great – and some of the Apps are great too – but we need to use our usual selection and consideration principles and make an educated decision about whether this is the best option for each user – or whether some of the other AAC technology currently available might suit their needs better. Or – in fact – whether a combination of technologies might have the best possible outcomes for a user. An iPad with an appropriate App with well designed vocabulary and appropriate support can be amazing – but we need to ensure that all our usual selection processes are used for each and every individual to ensure the best outcomes for them – whether this includes an iPad or not.

And to illustrate this point – I’d like to tell you about Crystal. Crystal is a 16 year old with complex communication needs. She has been using low tech communication books and high tech speech generating devices since she was very young. Currently she has a low tech PODD and a DynaVox MT4 with a PODD page set on it.

Crystal is independently mobile – but walking can be difficult for her and carrying her DynaVox MT4 hasn’t always been possible due to weight and size. Last year, her mother purchased an iPad and Proloquo2Go for her to use. Her mother’s initial plan was for this to be for her use at social events where her MT4 was too heavy for Crystal to carry.

Her school was delighted to hear that an iPad was coming. They suggested to her mother that the iPad was sent every day to school and her MT4 stop coming. Crystal’s mother spent around 40 hours trying to program all the vocabulary from her PODD page set into the iPad – and in the end she wasn’t able to do this completely as she had fewer symbol choices and reduced page layout options.

After several weeks her school suggested that the iPad didn’t need to come to school any more – and asked for her speech generating device to start coming again. They reported that it was much harder to Crystal to find vocabulary on her iPad and that it was slower for her to use to complete school work. The decision for school has been that her DynaVox MT4 remains the most appropriate tool for this situation. In fact, they are now upgrading to a DynaVox Maestro as they feel the bigger screen and increased portability of that unit might be an even better option for school.

However – in social situations the iPad and Proloquo2Go has taken on a life of its own. It breaks the ice – people who wouldn’t normally chat to Crystal with her low tech book or her Speech Generating Device are happy to walk up and start chatting – the iPad itself has become an incredible conversation starter as total strangers ask her how she likes it. Crystal can carry it independently – and is enjoying chatting with as many people as she can.

The iPad and Proloquo2Go alone wouldn’t meet her needs – but combining her DynaVox MT4 and her iPad has led to a communication system for Crystal that has had outcomes that no other communication options have given her. Each device is used in the most appropriate situation – leading to fewer communication breakdowns and much better outcomes for Crystal.

By Jane Farrall
24 April 2011, spectronicsinoz.com