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https://doi.org/10.1177/1053451217692569

Intervention in School and Clinic 2017, Vol. 53(1) 50 –57 © Hammill Institute on Disabilities 2017

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Technology Trends Cathy Newman Thomas, Associate Editor

Autism spectrum disorder (ASD) is a lifelong neurodevelop- mental disorder that manifests itself as deficits in communi- cation and social interaction skills, as well as the occurrence of repetitive behaviors (e.g., hand flapping, rocking back and forth) and restricted interests (American Psychiatric Association [APA], 2013). Individuals with ASD may have difficulties with verbal (e.g., abnormal volume/pitch/intona- tion, inability to convey wants using words) and nonverbal (e.g., impairment in the use of eye contact, gestures, body language) communication (APA, 2013). Communication skill deficits are common among individuals with ASD. It is estimated that about 30% to 50% of persons who are diag- nosed with ASD have no functional speech (National Research Council, 2001; Wodka, Mathy, & Kalb, 2013).

Augmentative Alternative Communication

Practitioners often use augmentative alternative communi- cation (AAC) devices to address the communication needs of individuals with ASD. According to Light, Roberts, Dimarco, and Greiner (1998), two types of AAC methods are used, unaided and aided. Unaided refers to the use of body parts to communicate (e.g., manual signs, gestures,

body language), and aided methods require the use of devices or support (e.g., pictures, communication symbols, text or words to create messages, speech-generating devices [SGD]). A SGD is a portable device that displays symbols (e.g., pictures and/or texts) as well as produces synthesized (text-to-speech) or digitalized speech upon activation (Shane et al., 2012). SGDs can be low-tech (e.g., GoTalk) or high-tech (e.g., Dynavox).

Mobile Technologies

Recently, the AAC field has been adopting the use of mobile touch-screen devices (e.g., tablets) and AAC applications (apps) as SGDs. The development in this field might be due to the features of the tablets not found in other AAC sys- tems (e.g., manual signs, picture exchange system). In

692569 ISCXXX10.1177/1053451217692569Intervention in School and ClinicAlzrayer and Banda research-article2017

1Department of Educational Psychology & Leadership, College of Education, Texas Tech University, Lubbock, TX, USA

Corresponding Author: Devender R. Banda, PhD, BCBA-D, Department of Educational Psychology & Leadership, College of Education, Texas Tech University, PO Box 41071, Lubbock, TX, 79409, USA. Email: [email protected]

Implementing Tablet-Based Devices to Improve Communication Skills of Students With Autism

Nouf M. Alzrayer, MEd1 and Devender R. Banda, PhD, BCBA-D1

Abstract Students with autism spectrum disorder (ASD) have difficulties in communication that limit their opportunities to participate in daily living and educational activities. Augmentative alternative communication is one of the strategies used to strengthen the communication skills of students with limited communication skills. Students with ASD commonly use handheld devices for communication. This article provides guidelines for special education teachers to support the implementation of tablet-based speech-generating devices in their classrooms. These guidelines may help special education teachers through the process of creating a student’s profile, conducting preference assessments, programming devices, and providing instruction in natural contexts.

Keywords communication skills, autism spectrum disorder, AAC, iPad, iPod, special education teachers

Alzrayer and Banda 51

addition, the use of tablets as AAC devices has several advantages including their socially acceptability, afford- ability, portability, availability, and flexibility (Blackwell, 2013; Clark, Austin, & Craike, 2014; McNaughton & Light, 2013; Rodriguez, Strnadová, & Cumming, 2013; Sandvik, Smørdal, & Østerud, 2012). However, these devices have certain disadvantages, such as selecting AAC apps without the consultations with professionals for evaluation and implementation (McNaughton & Light, 2013).

Research supports the use of tablets for improving com- munication skills in individuals with ASD and other devel- opmental disabilities. Investigators in several studies have reported an improvement in functional communication (e.g., requesting) and prosocial behaviors (e.g., decrease in aggression behaviors) in children and adolescents with ASD and developmental disabilities after the implementa- tion of tablets with AAC apps (Achmadi et al., 2014; Couper et al., 2014; Dundon, McLaughlin, Neyman, & Clark, 2013; King et al., 2014; Sigafoos et al., 2013; Ward, McLaughlin, Neyman, & Clark, 2013; Xin & Leonard, 2014).

Designers develop communication apps that run on these tablets (e.g., Apple iOS, Android devices), which are used as AAC systems by individuals with disabilities. Due to the extensive use of iPads/iPods and iOS apps as AAC devices for students with autism, this column focuses on the use of these devices. Professionals are encouraged to explore dif- ferent tablets and apps based on the communication needs of students with autism.

Apps

An app is defined as software that is designed for the user to complete a specific task (Brady, 2012). Research indicates that apps (e.g., Proloquo2Go) have improved communication skills in students with ASD. The literature review of Kagohara et al. (2013) revealed that apps can be used effectively for several purposes such as academic, communication, employ- ment, leisure, and transition. Another meta-analysis on iPads indicated that children and adolescents with ASD and devel- opmental disabilities could improve their social-communica- tion skills through the use of various AAC apps (Alzrayer, Banda, & Koul, 2014). One advantage of these AAC apps is the depth of features they offer. For instance, the Proloquo2Go has more than 7,000 symbols built into the program, and the Alexicom has 28 different language choices, which can be beneficial for bilingual students (Alliano, Herriger, Koutsoftas, & Barlotta, 2012).

Tablet-Based Systems in School Settings

Special education teachers and related service personnel (e.g., speech-language pathologists, behavior specialists) can implement iPads/iPods as SGDs successfully. The

following guidelines can benefit special education teachers who deal with students with ASD who are nonverbal or have very limited social-communication skills. These guidelines were created as a guide for special education teachers to select an iPad/iPod and AAC app that meets the student’s requirements and assist in implementing the method effectively. The guidelines can be modified based on the student’s abilities and requirements.

Assess the Student’s Related Abilities

A multidisciplinary team must collaborate to gather infor- mation about the student and create a comprehensive pro- file of wants and abilities (Beukelman & Mirenda, 2013). Gathering information about the student’s hearing, vision, motor skills (i.e., positioning, seating, selecting), linguis- tic and prelinguistic skills, problem behaviors, and cogni- tive abilities are important and will assist the individualized education program (IEP) team to select appropriate iPads or iPods and AAC apps. For example, enlarging the icon sizes and decreasing the screen sensitivity would be typi- cal modifications for a student with low vision and hand tremors. Other possible modifications for a student with limited attention span and low hearing abilities would be limiting the number of icons displayed (e.g., two icons on each page) and placing the iPad or iPod inside a case with a sound amplifier feature. A checklist (see Figure 1) can be used to ensure that all the skills are assessed before mov- ing on to the other steps. Special education teachers may need to use other published comprehensive assessment tools and frameworks to help select and implement an iPad/iPod-based SGD intervention, such as the Functional Evaluation of Assistive Technology (Raskind & Bryant, 2002) or the Student Environment Task Technology Framework (Zabala, 1995, 2002).

Symbol assessment is another area that is important for successful implementation of AAC. According Beukelman and Mirenda (2005), “The goal of symbol assessment is to select the types of symbols that meets the individual’s cur- rent communication needs and match his or her current abilities, as well as to identify the symbol options that might be used in the future” (p. 191). Symbols include photo- graphs, real or miniature objects, line drawings, or written words. Symbol assessment for students with severe com- munication problems involves several steps. First, a list of the student’s familiar items/activities from family members, special education teachers, or other frequent communica- tion partners needs to be obtained. Second, the special edu- cation teacher should assess the functional use of the objects. For example, the teacher can place a few items in front of the student and check if he or she uses them (e.g., eating with a spoon, trying to scribble with a pencil). Special education teachers should also evaluate the student’s ability to receptively label or name items in his or her environment.

52 Intervention in School and Clinic

Student’s Name:……………………… Class:…………………… Teacher:…………………….

1. Assess the student’s related abilities ( Check the item and describe each area):

Hearing and vision skill (e.g., does the student need hearing aids or corrective lenses?)

Fine motor skills (e.g., pointing accuracy; hand position; strength; tapping, swiping, and pinching, typing)

Symbols (e.g., the student’s ability to understand real object, photograph, words, or line drawing symbols)

Cognitive abilities (e.g., working memory, long-term memory, attention, perception skills)

Prelinguistic (e.g., pointing, making eye contact, pulling someone’s hands to get attention or request for preferred items)

Problem behaviors (e.g., screaming, self-injurious behaviors, aggression)

2. Select a device and app:

Tablet features required (e.g., screen size, weight, camera capabilities, sound)

AAC app features required (e.g., flexibility of customizing the app, quality of voice output, typing keyboard, stored vocabulary)

3. Conduct a preference assessment:

Preferred items and activities (e.g., parents/caregivers and/or teachers interviews, forced choice preference assessments, free play preference assessment)

Words/phrases (functional) used frequently on a daily basis (e.g., I need a break; I would like milk, please; I need help; more)

4. Teach AAC using systematic instructional methods:

Least-to-most prompting (e.g., verbal, gesture, partial or full physical)

Delayed prompting (e.g., provide prompts after 5s from the verbal cue “Let me know if you want a toy.”)

Differential reinforcement (e.g., give immediate access to the requested items if the student used the tablet for requesting.)

5. Collect intervention data and evaluate progress:

Progress from baseline to intervention (e.g., did the tablet-based requesting increased after starting the intervention?)

Modifications needed (e.g., enlarge the icon size, decrease the number of icons in each page, symbol discrimination training, decrease the sensitivity of the screen page)

6. Program for generalization:

Across people (e.g., parents/caregivers, teachers, school personnel, relatives)

Across settings (e.g., special and general education classrooms, home, community)

Across items (e.g., new items that share the same features of the preferred items/activities)

7. Teach operational skills:

Acquired operational skills (e.g., turning on/off the device, scrolling up/down, changing volume)

Skills needed to be acquired (e.g., typing, adding new icon, combine symbols, navigate through multiple pages)

Additional notes:

Figure 1. Practitioner checklist for mobile touch-screen devices as AAC system implementation for students with autism.

Alzrayer and Banda 53

Assessing receptive labeling can be done, for example, by placing two objects or pictures in front of the student and check if the student will be able to point to the correct object or picture named by the teacher. Some students with severe communication issues may not understand the verbal labels. In such cases, a visual-matching method can be used. For example, the teacher can provide an object and two symbols (one that exactly matches with the object) and see if the student matches the object with the symbol through point- ing or eye gaze. These basic symbol assessments assist the team in selecting appropriate items that are functional for students.

Furthermore, some students with ASD rely on prelinguis- tic skills (e.g., reaching, pointing, guiding someone’s hands toward a desirable item) as a way to communicate. However, holding and tugging on the teacher’s hands to indicate what the student wants might not be socially appropriate for an older child and an adolescent. Therefore, the special educa- tion teacher should document the communication form that a student uses to get attention or request for items and activi- ties. They also should record the frequency of the student requests using an appropriate form of communication (e.g., pointing, vocalization, facial expression) and inappropriate behaviors (e.g., self-injurious behaviors, physical aggres- sion). By doing so, the special education teacher can deter- mine the likelihood of the effectiveness of the intervention by comparing the number of times the student throws a tan- trum as a form of communication to the number of times the student uses the iPad to ask for attention or an item appropri- ately. If there is an increase in the frequency of the iPad/ iPod-based communication and a decrease in prelinguistic

or the challenging behaviors, then the teacher can say that the intervention shows positive results.

Select a Device and App

Choosing an appropriate iPad or iPod and an AAC app that matches the student’s characteristics and needs is the key for successful implementation of the intervention. For example, a teenage student with autism who has well- developed fine motor skills may benefit from using a tablet with a small screen (e.g., iPod). On the other hand, a tablet with a larger screen (e.g., iPad) may help another student with low vision to select the symbols more accurately. Furthermore, the special education teacher may need to use some type of protective cases for iPads or iPods to prevent any damage to the device, especially for students who engage in severe aggression behaviors frequently.

Selecting an appropriate AAC app is as important as selecting a device. A picture-based application (e.g., iComm) may be useful for students with autism who have low intel- lectual functioning and/or no prior AAC experiences. For students with ASD who are nonverbal and have a slightly wide vocabulary in their repertoire, the teacher might want to select advanced AAC apps that match their communica- tion level. Proloquo2Go (i.e., symbol/text-to-speech), for example, has three different stored vocabulary libraries that range from basic to advanced that can be selected and accus- tomed based on the student’s needs and characteristics (AssistiveWare, 2016). For more information about AAC apps, refer to Table 1. Additional information about AAC apps can also be obtained from AppsForAAC (n.d.).

Table 1. Augmentative Alternative Communication (AAC) Apps.

AAC App Developer Features Cost

Proloquo2Go AssistiveWare Synthesized speech (male, female) Word prediction

$219.99

PECS-Phase III

Pyramid Educational Consultants, Inc.

Multiple users Designed to train in visual discrimination

Free

Go Talk Now Attainment Company, Inc.

Add multiple pictures in symbols Visual and grid display

$79.99 Lite (free)

TapToTalka Assistyx LLC 2,600 pictures Record own voice

Free

OneVoice Legend 2-level page navigation Customize pictures

$199.99 Lite (free)

Voice4Ua Spectrum Visions Global, Inc.

160 stored symbols Display system (list and category)

$59.99

Alexicoma Alexicom Tech LLC List display (home page) Free My Talk Tools

Mobile 2nd Half Enterprises

LLC Program the system by using computer-

based web work space $99.99 Lite (free)

TouchChat Silver Kite Grid and visual-display screen $149.99 Lite (free)

iComm Bappz Record songs using own voice Yes/no choice screen

$7.99 Lite (free)

aThese apps operate on both iOS and Android operation systems.

54 Intervention in School and Clinic

Conduct a Preference Assessment

Motivation can be a key factor in the successful implemen- tation of AAC with students with autism (Light & Drager, 2007). Incorporating preferred items and activities into an intervention program helps to establish new behaviors (Tullis et al., 2011). Special education teachers can conduct preference assessments to identify preferred items and activities to facilitate learner motivation.

Preference assessments are typically conducted using indirect and direct methods (Cooper, Heron, & Heward, 2007). Special education teachers can ask parents and other caregivers about the student’s preferred items and activities. There are several ways to collect this information through interview protocols or surveys. The data about the student’s potential preferred items and activities can then be included in direct preference assessments. According to Cooper et al. (2007), there are two types of direct methods (e.g., natural observations, trial-based assessments). In natural observa- tions, the teacher records the student’s selection and engage- ment of preferred items and activities in different settings (e.g., classroom, playground).

Next, the teacher makes a list of activities and items that the student selected and engaged in frequently during free time. Conducting a trial-based or stimulus preference assessment is another method. In these assessment ses- sions, the special education teacher is required to present an item to the student and note the student’s response. The teacher records whether the student reaches for the item or rejects it, and the time the student spends engaged with the item. This process is well suited for students with a limited repertoire of preferred items. Forced choice is another method where the teacher presents two items simultane- ously and records the item selected across several pairs and trials to identify the preferred item(s). The teacher then can determine the most preferred items by calculating the per- centage of selection (number of times an item was selected/ number of times the item was offered). In a multiple-stim- uli method, the teacher can identify the most to least pre- ferred items and activities by asking the student to choose one item from an array of three or more items. The teacher then records the ranking of most to least preferred items and activities based on the order they were selected.

Identifying target behaviors (i.e., requests) that are used in daily routines is an essential step in implementing AAC interventions. Requesting skills are basic communication skills that are important to teach before proceeding to the other complex communication skills (Murphy & Barnes- Holmes, 2011) due to several reasons. First, students develop their language skills by learning how to express their wants. Second, providing preferred items upon requesting is likely to reinforce their requesting behavior. Third, teaching requesting skills establishes a foundation for the development of other verbal behaviors such as

labeling, commenting, and answering questions. One way to identify a vocabulary meaningful for the student is to conduct observations in contexts where the student is moti- vated to communicate. Results from preferences assess- ments will assist the team in selecting meaningful vocabulary and target behaviors. Programming an iPad/ iPod with words/phrases that the student rarely uses would more likely make the device meaningless for the student.

Systematic Instructional Methods

Special education teachers are encouraged to first target requesting skills in children with ASD using single words. For instance, a teacher could teach a student with ASD how to request music by tapping on the “Music” icon on Proloquo2Go app on an iPad. The teacher can then play music for the student. Learning how to request by using more complex sentences is also an important skill for stu- dents with limited communication needs. For example, the teacher can begin teaching the student to generate simple sentences by tapping the “I want” icon on the home screen and “Music” icon subsequently on the Proloquo2Go app. The student must press both the “I want” and “Music” icons to access the music. Similarly, more complex sentences can be taught by adding words such as “please” after making simple requests (e.g., “I want,” “Music,” “Please”) on the Prologquo2Go app. Additional strategies such as least-to- most prompting, time delay, discrete-trial teaching, and incidental teaching are recommended when teaching com- munication skills using iPads/iPods-based SGDs. Special education teachers, parents/caregivers, and other profes- sionals need to be trained on how to implement iPad/iPod- based SGDs through the assistive technology services at the school district, local, or a state agency.

Students with ASD can be taught to use the iPad/iPod to communicate by using the least-to-most prompting method (Duker, Didden, & Sigafoos, 2004). It is defined as provid- ing the least amount of assistance and increasing it gradu- ally, if necessary, to help the learner perform the response independently. For instance, the teacher can point to the target symbol for the student to activate the icon on the screen page. If the student does not respond, the teacher can provide additional prompts by physically guiding the stu- dent’s hand to activate the icon.

A time delay strategy can also be used in which the amount of time before delivering additional prompts is increased progressively (Duker et al., 2004). This method provides the learner increased opportunities to perform the response independently. For example, a teacher can provide additional prompts immediately (i.e., 0 seconds) after the verbal cue “Let me know if you want [Item’s name]” while holding the preferred item and then gradually increase the wait time before delivering the subsequent prompts (e.g., 5 seconds).

Alzrayer and Banda 55

Discrete trial teaching (Smith, 2001), a systematic instructional method that also includes the use of prompts, time delay, and reinforcement, can be used to teach request- ing skills to students with ASD. There are four steps that are used to train students with ASD to use the iPad to request toys/activities: (a) presenting the student with two preferred items and asking him or her (“What do you want to play with?”), (b) observing the student’s response, (c) providing prompts when needed (e.g., verbal, hand over hand), and (d) reinforcing the student’s behaviors by providing the requested item. Teaching should also occur beyond their self-contained classrooms or therapy settings. For example, the special education teacher or the paraprofessional can prompt the student to use the iPad to request for paints or papers during extracurricular activities in the art room.

Incidental teaching is another strategy for teaching commu- nication skills in natural settings such as home, playground, and community settings (Hart & Risley, 1975). Teaching in natural settings facilitates generalization of acquired skills, which are likely to sustain in similar contexts. Another strategy is to inter- rupt routines to create an opportunity for a student to request an item. For example, a teacher can interrupt the student’s ongoing play activity and ask him or her to request the same activity again by using the iPad (e.g., pressing “I want to play with Play- Dough” icon). Using such a method in training will help stu- dents acquire the skills of using iPads/iPods for communication and generalize those into new contexts. However, it is impor- tant to keep in mind not to give successive demands, which may lead the student to be less motivated to continue playing.

Collect Intervention Data and Evaluate Progress

Data collection during the teaching phase is important to evaluate the impact of an iPad/iPod as an AAC intervention. Teachers can compare data on requesting skills from base- line to intervention phases through simple graphs (e.g., line or bar graph) to see if the intervention is indeed effective. If a student’s requesting skills do not increase after introduc- ing the iPads/iPods-based AAC intervention across five to six teaching sessions, it is important to reevaluate and con- sider additional strategies or modifications.

Program for Generalization

Communication skills should be generalized across multiple stimuli, settings, and people to promote the use of the iPad/ iPods-based SGD. Generalization refers to applying the learned response in novel situations (Cooper et al., 2007). Programming for generalization includes providing training opportunities throughout the day across different settings, communication partners, and items. For example, a teacher could provide students with ASD with opportunities to request for novel items/activities (e.g., playing with animals, listening to a story), across settings (e.g., general education

classrooms, playground), and with different communication partners (e.g., peers, paraprofessionals, general education teachers). In addition, the teacher could promote the stu- dent’s novel communication skills (e.g., labeling, answering questions). When a student is able to request (e.g., I want chips, please) independently, the teacher could then train the student to label a picture of the chips and answer why and how questions (e.g., what is your favorite snack?).

Teach Operational Skills

An AAC user has to acquire operational skills to use the iPads/ iPods independently. Such skills include turning on and off the device, changing the volume, and swiping to move to the next page. Additional operational skills include but are not limited to accessing the app, selecting the category and the specific symbols, scrolling down the page to see more sym- bols, and combining symbols to create sentences. Operational skills may differ slightly based on the complexity of the AAC app. For example, some apps require the user to only tap on the icon; others are more sophisticated in that the user needs to select multiple categories to reach the target icon. Teachers can break down the steps required to use an iPad or iPod into teachable tasks before starting an intervention with the stu- dent. An example of how to open an app includes the follow- ing tasks: (a) push the home button on the iPad or iPod to turn on the device, (b) swipe to the right to unlock the screen, (c) swipe to the left side to turn to the second page, and (d) touch the target icon to access the app. Systematic instructional strategies as described previously (e.g., least-to-most prompt- ing, time delay) may be used to teach operational skills (Achmadi et al., 2012). Teachers should start the operational skills training as early as possible. At the beginning stage of training, the student should learn how to select a single sym- bol to receive a preferred item. Gradually, the complexity of the training should increase to learning how to combine two to three symbols displayed across multiple pages.

Conclusions

The recent developments in mobile devices and touch screen technology offer new teaching opportunities for pro- fessionals working with students with ASD. Research shows that the use of iPad/iPod-based SGDs may be an effective method to improve communication skills in stu- dents with ASD. By following the steps and procedures described in this article, teachers may implement iPads/ iPods with AAC apps, measure progress, and evaluate their effectiveness with students with ASD.

Disclaimer of Interests

These guidelines are not specific to a brand, but they rather focus on how to program and implement a tablet-based AAC interven- tion with students with ASD who are in need for AAC services.

56 Intervention in School and Clinic

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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