J Autism Dev Disord DOI 10.1007/s10803-014-2266-8
BRIEF REPORT
Using iPads to Teach Communication Skills of Students with Autism Joy F. Xin • Deborah A. Leonard
Ó Springer Science+Business Media New York 2014
Abstract The purpose of this study was to examine the effects of using an iPad to assist students with autism in learning communication skills. Three, 10 years old learners diagnosed with autism who present little or no functional speech, participated in the study. A multiple baseline design with AB phases across academic and social settings was used. During the baseline, students were given access to an iPad with the SonoFlex speech-generating device application, while no communicative attempts were observed. During the intervention, the students were taught to use the iPad to communicate with their teacher and peers for 6 weeks. With a least-to-most prompting hierarchy, all students increased initiating requests, responding to questions and making social comments in both class and recess settings. Keywords
Technology Autism Communication
Introduction Many students with autism spectrum disorders (ASD) present little or no functional speech (National Research Council 2001). They rely on behaviors such as pointing, reaching, eye gazing, and various facial expressions to present their needs. To help these students learn J. F. Xin (&) Department of Language, Literacy and Special Education, Rowan University, 201, Mullica Hill Rd, Glassboro, NJ 08028, USA e-mail: [email protected] D. A. Leonard J. Mason Tomlin School, Mantua Township, NJ, USA e-mail: [email protected]
communicative skills, Augmentative and Alternative Communication (AAC) approaches are suggested (Bondy and Frost 2002). AAC devices provide symbols, pictures, photos, and written words to communicate thoughts and ideas in visual presentations that are inanimate, predictable, and more static than speech (Mineo et al. 2008). These features typically motivate students with ASD who often dislike changes and prefer consistency. New concepts and associated vocabulary can be added to the existing symbols, which make the learning process consistent and stable with minimal disruptions to a familiar routine. This may reduce learning anxiety by creating a gradual introduction of new language as well as an easy way to accurately communicate a student’s needs by simply touching or pointing to a symbol or image (Mineo et al. 2008). It seems that visual language on AAC devices is easier for minimally verbal students to understand than speech and manual signs, thus maximizing the comparatively strong visual processing skills of those with ASD (Shane et al. 2012). Understanding and following the complex cues involved in speech are difficult for students with ASD (Mirenda 2003). To assist these students, AAC devices can be programmed with simple cues using one symbol, increasing cues with many symbols as they gradually learn to understand and express themselves with more complex words. An option of AAC is a speech-generating device (SGD). A SGD provides speech that is generated by touching/pressing an icon, which may be a symbol or image on a communication device, resulting in the audible expression of the icon selected. It was found that children who were taught to use individual SGDs with line drawing symbols to represent messages such as ‘‘I want a snack, please,’’ ‘‘more,’’ and ‘‘I need help.’’ with a naturalistic teaching procedure such as child-preferred stimuli, natural
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cues (e.g. expectant delays and questioning looks to elicit communication), and non-intrusive prompting techniques increased their interactions with classroom staff (Shane et al. 2012). Current technology such as the Apple iPad, using specialized AAC applications (apps), provides an opportunity for students with ASD to meet their communication needs (Shane et al. 2012). For example, some apps (e.g. Proloquo2go, MyTalk, SonoFlex) designed for these devices can serve as a full high-tech AAC system (Shane et al. 2012). The adoption of the new portable hardware and software provides a significant paradigm shift in AAC that is readily available to consumers in a small sized device, easy to transport, and at a relatively low cost (Shane et al. 2012). IPads are being used in general education classrooms to engage students in learning to promote higher-level thinking and problem solving (Pilgrim et al. 2012). These resources also support special education teachers and students to access content and skill specific applications (Blood et al. 2011). For example, teachers can control settings to specific skills or ability levels and monitor student progress. Engaging apps make drills and practice more interesting for students, and the immediate and consistent feedback is beneficial for their learning (Pilgrim et al. 2012). To date, there are many communication applications available for iPads to function as an AAC device. However, research on iPads as AAC devices was only found in the application of Proloquo2Go, except one study that used Pick a Word (Van der Meer et al. 2011), though there are many anecdotal reports about students with ASD learning communication skills using these software apps (Sennott and Bowker 2009). More empirical studies using an iPad as a SGD are needed to evaluate the technology and software, and to find another avenue for meeting the communication needs of those who have limited speech and language. This opportunity would also enable teachers and speech-language pathologists to make evidence-based decisions when choosing an appropriate AAC device and software application for their students, as well as make an argument for funding to purchase the technology. Functional spontaneous communication during daily tasks should be the measure of a successful AAC intervention (Shane et al. 2012). Thus, additional studies on expressive language acquisition using an iPad and its applications are needed to verify previous findings and add information to the learning outcomes of students with ASD. Our study attempts to expand previous research on mobile technology by using an iPad with an AAC application for communication purposes in natural school settings. Instead of Proloquo2Go, another program with much less cost, called SonoFlex was used to teach these students communication skills. The purpose of our study is to determine the effect of iPads as an AAC device on spontaneous functional communication
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responses in school settings, such as classroom and recess. Specifically, the research questions are presented as follows. (1). Will the students with ASD increase their expressive communication, e.g. initiating requests, responding to questions, and making social comments when using an iPad? (2). With a least-to-most prompting hierarchy, will these students increase spontaneous (e.g. unprompted) communication with their teacher and peers when an iPad is applied?
Participants Three 10-year-old students, one female and two males, diagnosed with ASD and a moderate cognitive disability, attending a public school, participated in this study. All students were diagnosed with limited speech and language abilities at age of 4. Prior to the study, Vineland Adaptive Behavior Scales (2nd Edition, 2005) and Wechsler Intelligence Scale for Children (4th Edition, 2003) were administered. Table 1 presents the general information of the participating students. Student 1, Eric, attempted to communicate by leading an adult towards what he wanted. Through the teacher’s observations, it was found that he did not speak any words, but yelled and bit the palm of his hand when tasks or assignments were presented. Student 2, Christian, was usually very quiet and compliant. Based on teacher observations, it was hypothesized that he engaged in hand flapping with a single loud scream because of his uncertainty of expectations or stress. He seemed to try to speak occasionally by opening his mouth with intention, but no words were uttered. Student 3, Samantha, scripted a few spoken words in a frantic sounding fashion (e.g., ‘‘swing’’, ‘‘break please’’, ‘‘No, thank-you’’) when she was asked to do something, but rarely spoke unless prompted to do so by an adult. She was able to repeat a word that was modeled Table 1 General information of participating students Student
WISC, IQ scores
Expressive language**
Receptive language**
Student 1 (Eric)
\75
Non-verbal
No score due to interfering behaviors during testing attempts
Student 2 (Christian)
\75
Non-verbal
No score. Records indicate he pointed to all responses for each question 55, which is considered ‘‘Low’’ (higher than 1 % of her peers)
Student 3 \75 (Samantha)
\2 years old
* Wechsler Intelligence Scale for Children (4th Edition), Mean: 100 ** Vineland Adaptive Behavior Scales (2nd) Edition
J Autism Dev Disord Table 2 Examples of communications
Table 3 Least-to-most prompting hierarchy
Types of communication
Examples
Level of prompts
Scores
Examples
Request
‘‘I want cereal.’’
Independent
5
The student initiates a communication without any help. This is considered a non-prompted communication
Verbal
4
The student is given verbal directives such as, ‘‘Choose a button.’’ or, ‘‘Do you want ‘x’ or ‘y’?’’ or, ‘‘Tell Samantha it’s your turn’’
Gesture
3
Pointing to the specific area that the student should be looking at to make a communication attempt
Model
2
Select the correct button and then give the students the opportunity to select the button by themselves
Physical
1
Using a hand-over-hand process, guide the student to make the correct communication. Provide an opportunity for the students to make the selection by themselves
Not communicative
0
Student was not attentive to instruction and/or showed unwillingness to communicate with the iPad
‘‘I want a break.’’ ‘‘I want to use the bathroom.’’ Response
What is your name? ‘‘Eric’’ What is the weather? ‘‘Sunny’’ Where did we go today? ‘‘Bowling’’
Social comment
‘‘I like it!’’ ‘‘I am sorry.’’ ‘‘It’s your turn’’
for her in response to a question. Verbal prompts were provided but her words uttered were always isolated and hard to understand. Each of the students had an individual education program (IEP) in which the goals of learning to use a SGD to communicate basic needs/wants, responding to questions and making appropriate social comments were addressed. All students were placed in a special education classroom with a teacher who taught the lessons, and two teacher assistants (TA).
Instructional Materials An iPad with a protective cover and carrying handles was provided to each student. Sonoflex, a SGD app was downloaded onto each iPad. The Sonoflex icon was placed in the lower right-hand corner of the opening screen page for consistent ease of access. By tapping on the icon, the Sonoflex screen page opens and displays category buttons, called ‘‘contexts’’, that when touched, open to vocabulary screens that are programmed with appropriate Symbolstix picture icons, or photographs (see Appendix 1). When the student selects an icon by touching a button on the screen, computer generated speech for that icon is produced using a gender/age appropriate voice. A single word or a complete sentence may be programmed on each button. For example, when the numeral 4 is touched, the iPad speaks: ‘‘four’’, when the icon with snacks is touched, the sentence: ‘‘I want a snack, please.’’ is spoken. On the home page of the Sonoflex app, the following context buttons were created by the teacher: ‘‘Morning Meeting’’, ‘‘Math’’, ‘‘Reading’’, ‘‘Social Studies’’, ‘‘I want’’ and ‘‘Being Friendly’’ (see Appendix 2 for an example of vocabulary words presented on the context screen).
Measurement Material An observation checklist was developed by the teacher to record the types of communication and prompting levels to
make a response using an iPad. Each type of communication was tallied as a request, response, or social comment, and a prompt score was assigned to indicate the level of support required to assist the student in using the iPad to communicate with an individual (see Tables 2, 3). Median scores were calculated to present appropriate ordinal data based on prompting levels from 0 to 5 for each type of communication.
Research Design and Procedure A single subject, multiple-baseline design with AB phases across settings was used. During the baseline, data were collected during two 10-min sessions 2 days per week for 2–3 weeks. The sessions included one academic lesson (Language Arts) and one recess-time, such as after lunch, to provide opportunities for social comments and requests. During this phase, a session began when an academic lesson started or when the participant was dismissed for a break. The students were verbally instructed, ‘‘Get your iPad and turn on SonoFlex.’’ After accessing the SonoFlex app, they were instructed to select the specific context button. The iPad was positioned lying flat on the right side of their desk without any support. If it was an academic session, the teacher presented the scheduled lesson for that day, and data were collected by recording each of the teacher’s questions as a response and all student responses were recorded without providing any prompts. A minimum of 5 questions were presented. If the student responded,
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initiated a request or made a social comment using the iPad, it was scored 5 as an independent communication. If the iPad was not used to respond, 0 was scored. If it was recess-time, the iPad was placed in the area (usually within 5 feet) where students were taking their break. If they left the area, no reminders of taking the iPad were given. Any responses, requests or social comments using the iPad were recorded. During the intervention, data collection was continued in the same sessions 2 days per week for 6 weeks. Instruction was provided using the least-to-most prompting hierarchy after a 5-s pause. For example, during a Language Arts lesson, the teacher asked, ‘‘Samantha, which word starts the same as ‘car’?’’ The teacher waited for her response, by expectantly looking at her for 5-s. If no response was given, the TA would verbally direct, ‘‘Answer with your iPad.’’ Again, a 5-s pause was provided. If there was still no response, the question was asked again, with the same tone of voice. If no response was given within 5-s, the TA pointed to the correct iPad button, providing a gesture prompt. If, after a 5-s pause there was no response, the question was re-asked. The TA then provided a model prompt by touching the correct button and then gave the student the opportunity to select the button within 5 s. If no response occurred, the question was asked again (still using the same tone as the first time) and the TA immediately guided the student physically to touch the correct button on the iPad. This was followed by an opportunity to touch the button if the student wanted to, by saying, ‘‘Good touching the button to answer, now you try.’’ If the student chose to touch the button on his/her own, social praise was given; if not, the lesson continued without further comment on the question or response. The process was repeated for each type of communication. During a recess session, the student was prompted to request the item using the iPad when observed to have a Table 4 Total number, mean scores and standard deviations of requests, responses, and social comments
Student
particular need, such as staring at a desired toy (request); a social opportunity was provided by starting a game and then saying, ‘‘Whose turn is it?’’ (response) or, after doing a puzzle together, prompting the social comment, ‘‘That was fun.’’ (comment)
Data Analysis A visual analysis of the observation data compared the baseline and intervention for each participant in both class and recess settings, as well as the total number of responses and means. In addition, the percentage of non-overlapping data (PND) procedure described by Scruggs et al. (1987) was used. The guideline recommended by Asaro-Saddler and Saddler (2010) was adopted. This guideline generated a PND score of 90 %, indicating the intervention points exceeding the extreme baseline value for a very effective treatment; 70–90 %, an effective treatment; 50–69 %, indicating some effect, and less than 50 %, a questionable treatment (see Table 4).
Results Table 4 presents the total number of occurrences in each type of communication, and the means and standard deviations across phases. Figure 1 presents individual student’s scores of requests in academic and social settings across the baseline and intervention. Results show that Eric made 13 requests, of those 9 were in the academic and 4 in the social sessions with a mean of 1.67 and .50 respectively. Christian made 12 requests (6 in the academic and 6 in the social sessions with a mean of 1.42 and 1.25); Samantha made 12 requests (6 in the academic and 6 in the social sessions with a mean of 1.79 and 1.72) during the
Phase A Total
Phase B
Total (C)
Mean (C)
SD
PND (%)
Total (R)
Mean (R)
SD
PND (%)
Eric Requests
0
9
1.67
1.37
75
4
.50
.90
34
Responses Comments
0 0
50 9
2.22 1.71
.66 1.17
100 75
27 46
2.01 2.37
.98 .79
83 100
Christian Requests
0
6
1.42
1.78
50
6
1.25
1.71
50
Responses
0
60
3.70
.97
100
21
3.59
1.04
100
Comments
0
10
2.83
1.04
83
58
3.14
.65
100 50
Samantha
C Class, R Recess
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Requests
0
6
1.79
1.90
50
6
1.67
1.72
Responses
0
61
3.38
1.23
100
15
3.50
1.61
92
Comments
0
9
2.67
1.67
75
60
3.32
.42
100
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intervention, while no one made any requests during the baseline. Although all students increased their requests using the iPad, Eric only made 4 requests out of 12 sessions in recess, generated a PND score of 34 %, indicating a questionable treatment. Both Christian and Samantha made 6 requests in both academic and social settings, generated a PND score of 50 %, indicating some effect of the intervention. Figure 2 presents individual student’s scores of responses across phases. Eric responded to 77 questions (50 in class and 27 in recess with a mean of 2.22 and 2.01 respectively); Christian responded to 81 questions (60 in class and 21 in recess with a mean of 3.7 and 3.59); and Samantha responded to 76 questions (61 in class and 15 in recess with a mean of 3.38 and 3.5) during the intervention, while none of them responded during the baseline. All students increased their responses to questions both in class and recess, especially in class, presenting PND scores of 83–100 % to indicate a very effective treatment (see Table 4). Figure 3 presents each participating student’s scores of social comments across phases. Eric made 56 comments (10 in class and 46 in recess with a mean of 1.71 and 2.37 respectively); Christian made 68 social comments (10 in class and 58 in recess with a mean of 2.83 and 3.14); and Samantha made 69 social comments (9 in class and 60 in recess with a mean of 2.67 and 3.32) during the intervention, while no comments of any students were found during the baseline. All students made comments in both academic and social settings, especially during recess, presenting PND scores of 75–100 %, indicating an effective treatment (see Table 4).
Discussion Our study attempts to evaluate the expressive communication of students with ASD using an iPad with the SonoFlex app in school settings. They were taught to use the iPad with the communication application in learning initial requests, response to questions, and making social comments with a decreasing level of prompts. During the baseline, none of the participants were able to express themselves, and no attempts were made to use the iPad for communication, despite the available access. Same observations were found during the recess, no students used the iPad to communicate with the adults and peers. During the intervention, all participants were receptive to instruction in both academic and social settings. Results showed an increase of their initial requests indicating their needs by touching the icon on the iPad screen with reduced prompts. However, initiating (expressive language) is comparatively harder than responding to questions for
students with ASD (Tiegerman 1993). Comparing to responses to questions and making social comments, the number of initial requests is low. Requests (or mands) are of direct benefit to the speaker, and the motivation to request could be high if the speaker gains access to the requested object or activity preferred (Kagohara et al. 2012). Thus, using highly preferred objects and activities (child-preferred stimuli) to increase students’ requests should be considered during instruction. In addition, continuous instruction with prompts is needed to encourage students to express themselves and initiate their needs which are functional in school. Intensive and frequent interactions (Nind 1999) between teachers and students in both class and social settings should be provided to improve their initiation for communication. Responding to questions is a vital communication skill in the classroom. It allows teachers to assess student comprehension as well as better understand individual needs. During the intervention, all students were engaged in the academic lessons as they scanned the vocabulary words available and touched the screen to respond to the teacher’s questions. Results show that two of the participants (Christian and Samantha) reached the level of independence without prompting (highest score of 5), and the other (Eric) gained scores. These scores not only present the improvement of their communication, but also provide important feedback for the teacher to adjust instruction accordingly to meet all students’ needs. It seems that the use of an iPad strongly supports non-verbal students with ASD to participate in class activities and interact with the teacher. Encouraging social comments from the students promoted their awareness of others in the environment. All participants showed improved skills to make appropriate social comments. The results show that two students reached the highest score of 5 with independence without prompting sometimes, and the other gained scores. All participants made more comments during recess than they did in class. It seems that more opportunities are available for students to make comments on the activities (e.g. games) during recess than the structured class. As indicated by Tiegerman (1993), social situations are very important for autistic students with communication deficits. Thus, the social opportunity should be offered frequently for students with ASD to participate in school activities so that they can continue to learn communication skills and to increase their social interactions with peers and teachers. Further, increasing communication opportunities in social settings will make these students socially recognizable as school members, which will promote their future inclusion in general education classrooms with typically developing peers. In accordance with the findings reported in the previous research (e.g. Kagohara et al. 2012), our study has
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Fig. 1 Median scores of each student’s use of the iPad to make requests during academic and social settings
expanded to an application of the SonoFlex as AAC to support non-verbal students with ASD. The iPad serves as a viable technological aid. Using the SonoFlex application as the communication program not only increased their responses to teacher’s questions in class, but also promoted
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skill learning to other settings such as recess. Our results showed that iPads provided students with ASD an opportunity to communicate with their teachers in class and interact with peers in recess. This opportunity would encourage these students to join with typically developing
J Autism Dev Disord
Fig. 2 Median scores of each student’s use of the iPad to make responses during academic and social settings
students in social sessions, such as lunch and recess. Using an iPad is potential for these students to initiate, respond to, and make comments, which will lead them to communicate with their peers in school. Making friends with typically developing peers often is difficult for students with
disabilities, especially for those with limited speech and language skills (Mazurek and Kanne 2010). Individuals with ASD have significantly less frequent contact with friends, fewer friendships, and lower frequency of meeting when compared to typically developing peers (Bauminger
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Fig. 3 Median scores of each student’s use of the iPad to make comments during academic and social settings
and Kasari 2000). Using mobile devices such as iPads will allow these students to carry to social settings to interact with peers using this SGD as a communication tool. This will definitely create an avenue for students with disabilities to communicate with others, learning skills to make friends and build friendship.
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Despite positive results of the study, there are some limitations. First, only three participating students and a short time period of 6 weeks’ instruction may be difficult to generalize the findings to other settings and students. The lack of independent initiation (request) presented by the data may leave the question of whether the use of an
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iPad and associated software (app) is part of a meaningful functional communication system for students with autism. According to Kagohara et al. (2012), systematic instruction consisting of time delay, least-to-most prompting, and reinforcement with a SGD is strongly recommended for students with ASD to learn functional communication skills. Thus, continued intervention with intensive and frequent interactions (Nind 1999) between teachers and students is needed to determine the potential of using the iPad for functional communication, in order for students to achieve more independent levels. We believe that with continued instruction and reduced prompts, the use of an iPad as a SGD will be meaningful and effective. Second, students’ requests, responses and comments were only recorded in two settings, class and recess, though they were in natural school environments. It would be stronger if another setting was included where the students could further learn the communication skills with their iPad as well as their skill generalization in other settings to validate the finding. In addition, the SonoFlex app has some limited features, such as a fixed icon size and all related vocabulary visible on the same screen. Some students would be more successful with larger and fewer icons on a screen, which can link to more specific vocabulary as the student develops proficiency in the use of AAC. Selecting the most appropriate AAC app for each student based on individual needs should be considered.
Implications Communication skills are important for individuals, especially for those with ASD who have little and no functional speech. They are the candidates for AAC approaches to replace or supplement natural speech. AAC provides these students an opportunity to express themselves, present their needs and wants, and interact with their teachers, peers, friends and family members. Currently, there are many AAC devices on the market for families and schools to select, however, most of them are expensive. An iPad with apps may provide an alternative opportunity for these students. To date, many families may already have an iPad in their homes and are already familiar with its use. Using a relatively inexpensive iPad app that can be easily downloaded for students to access may lead to improved communication between children and parents at home, as well as interaction with their peers without disabilities in school. We believe that the iPad for communication purposes for students with ASD will increase as its popularity in our daily lives and its potential to serve as a communication tool in school.
Appendix 1 See Fig. 4.
Fig. 4 Vocabulary Screen for ‘‘Social Studies’’ context button
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Appendix 2 See Table 5. Table 5 Examples of context buttons and associated vocabulary words
SonoFlex context buttons
Vocabulary buttons
Morning meeting
Math
Reading*
Social studies*
I want
Being friendly
Bowling
Monday
0
Emily
Circus
food
My name is
Shoes, size
Tuesday
1
Touch
Fun
drink
Hi
Ball
Wednesday Thursday
2 3
Taste Smell
Juggler Ringmaster
bathroom break
Bye Classmate
Strike Spare
Friday
4
See
Animals
outside
Classmate
My turn
January
5
Hear
Elephant
iPad
Classmate
Your turn
February
6
I
Lion
home
Classmate
Thanks!
March
7
Can
Tiger
Smartboard
Staff
Bathroom
Gym
8
Birthday
Horses
O.T. room
Staff
Drink
Music
9
Red
Website
book
Staff
Snack
Library
10
Loud
Train
Quiet
Staff
I’m tired
Sign Language
Add
Sweet
Ringling brothers
Help
School Name
That was fun!
Sunny
Subtract
Rough
January
yes
My turn
Thank you
Rainy
More
Good
I
no
Your turn
Bus
Snowing
Less
Ran
Like
More, please
Thanks
Break
Cold
The same
Man
Work
Go home?
I had fun!
I did it!
Hot
All done
Van
Yes
Stop, please
Yes
Yes
Yes
Fan
No
I’m good
No
No
No
Yes
I’m sorry
No
Yes
* The words are changed to match the current lesson being taught
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BRIEF REPORT
Using iPads to Teach Communication Skills of Students with Autism Joy F. Xin • Deborah A. Leonard
Ó Springer Science+Business Media New York 2014
Abstract The purpose of this study was to examine the effects of using an iPad to assist students with autism in learning communication skills. Three, 10 years old learners diagnosed with autism who present little or no functional speech, participated in the study. A multiple baseline design with AB phases across academic and social settings was used. During the baseline, students were given access to an iPad with the SonoFlex speech-generating device application, while no communicative attempts were observed. During the intervention, the students were taught to use the iPad to communicate with their teacher and peers for 6 weeks. With a least-to-most prompting hierarchy, all students increased initiating requests, responding to questions and making social comments in both class and recess settings. Keywords
Technology Autism Communication
Introduction Many students with autism spectrum disorders (ASD) present little or no functional speech (National Research Council 2001). They rely on behaviors such as pointing, reaching, eye gazing, and various facial expressions to present their needs. To help these students learn J. F. Xin (&) Department of Language, Literacy and Special Education, Rowan University, 201, Mullica Hill Rd, Glassboro, NJ 08028, USA e-mail: [email protected] D. A. Leonard J. Mason Tomlin School, Mantua Township, NJ, USA e-mail: [email protected]
communicative skills, Augmentative and Alternative Communication (AAC) approaches are suggested (Bondy and Frost 2002). AAC devices provide symbols, pictures, photos, and written words to communicate thoughts and ideas in visual presentations that are inanimate, predictable, and more static than speech (Mineo et al. 2008). These features typically motivate students with ASD who often dislike changes and prefer consistency. New concepts and associated vocabulary can be added to the existing symbols, which make the learning process consistent and stable with minimal disruptions to a familiar routine. This may reduce learning anxiety by creating a gradual introduction of new language as well as an easy way to accurately communicate a student’s needs by simply touching or pointing to a symbol or image (Mineo et al. 2008). It seems that visual language on AAC devices is easier for minimally verbal students to understand than speech and manual signs, thus maximizing the comparatively strong visual processing skills of those with ASD (Shane et al. 2012). Understanding and following the complex cues involved in speech are difficult for students with ASD (Mirenda 2003). To assist these students, AAC devices can be programmed with simple cues using one symbol, increasing cues with many symbols as they gradually learn to understand and express themselves with more complex words. An option of AAC is a speech-generating device (SGD). A SGD provides speech that is generated by touching/pressing an icon, which may be a symbol or image on a communication device, resulting in the audible expression of the icon selected. It was found that children who were taught to use individual SGDs with line drawing symbols to represent messages such as ‘‘I want a snack, please,’’ ‘‘more,’’ and ‘‘I need help.’’ with a naturalistic teaching procedure such as child-preferred stimuli, natural
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cues (e.g. expectant delays and questioning looks to elicit communication), and non-intrusive prompting techniques increased their interactions with classroom staff (Shane et al. 2012). Current technology such as the Apple iPad, using specialized AAC applications (apps), provides an opportunity for students with ASD to meet their communication needs (Shane et al. 2012). For example, some apps (e.g. Proloquo2go, MyTalk, SonoFlex) designed for these devices can serve as a full high-tech AAC system (Shane et al. 2012). The adoption of the new portable hardware and software provides a significant paradigm shift in AAC that is readily available to consumers in a small sized device, easy to transport, and at a relatively low cost (Shane et al. 2012). IPads are being used in general education classrooms to engage students in learning to promote higher-level thinking and problem solving (Pilgrim et al. 2012). These resources also support special education teachers and students to access content and skill specific applications (Blood et al. 2011). For example, teachers can control settings to specific skills or ability levels and monitor student progress. Engaging apps make drills and practice more interesting for students, and the immediate and consistent feedback is beneficial for their learning (Pilgrim et al. 2012). To date, there are many communication applications available for iPads to function as an AAC device. However, research on iPads as AAC devices was only found in the application of Proloquo2Go, except one study that used Pick a Word (Van der Meer et al. 2011), though there are many anecdotal reports about students with ASD learning communication skills using these software apps (Sennott and Bowker 2009). More empirical studies using an iPad as a SGD are needed to evaluate the technology and software, and to find another avenue for meeting the communication needs of those who have limited speech and language. This opportunity would also enable teachers and speech-language pathologists to make evidence-based decisions when choosing an appropriate AAC device and software application for their students, as well as make an argument for funding to purchase the technology. Functional spontaneous communication during daily tasks should be the measure of a successful AAC intervention (Shane et al. 2012). Thus, additional studies on expressive language acquisition using an iPad and its applications are needed to verify previous findings and add information to the learning outcomes of students with ASD. Our study attempts to expand previous research on mobile technology by using an iPad with an AAC application for communication purposes in natural school settings. Instead of Proloquo2Go, another program with much less cost, called SonoFlex was used to teach these students communication skills. The purpose of our study is to determine the effect of iPads as an AAC device on spontaneous functional communication
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responses in school settings, such as classroom and recess. Specifically, the research questions are presented as follows. (1). Will the students with ASD increase their expressive communication, e.g. initiating requests, responding to questions, and making social comments when using an iPad? (2). With a least-to-most prompting hierarchy, will these students increase spontaneous (e.g. unprompted) communication with their teacher and peers when an iPad is applied?
Participants Three 10-year-old students, one female and two males, diagnosed with ASD and a moderate cognitive disability, attending a public school, participated in this study. All students were diagnosed with limited speech and language abilities at age of 4. Prior to the study, Vineland Adaptive Behavior Scales (2nd Edition, 2005) and Wechsler Intelligence Scale for Children (4th Edition, 2003) were administered. Table 1 presents the general information of the participating students. Student 1, Eric, attempted to communicate by leading an adult towards what he wanted. Through the teacher’s observations, it was found that he did not speak any words, but yelled and bit the palm of his hand when tasks or assignments were presented. Student 2, Christian, was usually very quiet and compliant. Based on teacher observations, it was hypothesized that he engaged in hand flapping with a single loud scream because of his uncertainty of expectations or stress. He seemed to try to speak occasionally by opening his mouth with intention, but no words were uttered. Student 3, Samantha, scripted a few spoken words in a frantic sounding fashion (e.g., ‘‘swing’’, ‘‘break please’’, ‘‘No, thank-you’’) when she was asked to do something, but rarely spoke unless prompted to do so by an adult. She was able to repeat a word that was modeled Table 1 General information of participating students Student
WISC, IQ scores
Expressive language**
Receptive language**
Student 1 (Eric)
\75
Non-verbal
No score due to interfering behaviors during testing attempts
Student 2 (Christian)
\75
Non-verbal
No score. Records indicate he pointed to all responses for each question 55, which is considered ‘‘Low’’ (higher than 1 % of her peers)
Student 3 \75 (Samantha)
\2 years old
* Wechsler Intelligence Scale for Children (4th Edition), Mean: 100 ** Vineland Adaptive Behavior Scales (2nd) Edition
J Autism Dev Disord Table 2 Examples of communications
Table 3 Least-to-most prompting hierarchy
Types of communication
Examples
Level of prompts
Scores
Examples
Request
‘‘I want cereal.’’
Independent
5
The student initiates a communication without any help. This is considered a non-prompted communication
Verbal
4
The student is given verbal directives such as, ‘‘Choose a button.’’ or, ‘‘Do you want ‘x’ or ‘y’?’’ or, ‘‘Tell Samantha it’s your turn’’
Gesture
3
Pointing to the specific area that the student should be looking at to make a communication attempt
Model
2
Select the correct button and then give the students the opportunity to select the button by themselves
Physical
1
Using a hand-over-hand process, guide the student to make the correct communication. Provide an opportunity for the students to make the selection by themselves
Not communicative
0
Student was not attentive to instruction and/or showed unwillingness to communicate with the iPad
‘‘I want a break.’’ ‘‘I want to use the bathroom.’’ Response
What is your name? ‘‘Eric’’ What is the weather? ‘‘Sunny’’ Where did we go today? ‘‘Bowling’’
Social comment
‘‘I like it!’’ ‘‘I am sorry.’’ ‘‘It’s your turn’’
for her in response to a question. Verbal prompts were provided but her words uttered were always isolated and hard to understand. Each of the students had an individual education program (IEP) in which the goals of learning to use a SGD to communicate basic needs/wants, responding to questions and making appropriate social comments were addressed. All students were placed in a special education classroom with a teacher who taught the lessons, and two teacher assistants (TA).
Instructional Materials An iPad with a protective cover and carrying handles was provided to each student. Sonoflex, a SGD app was downloaded onto each iPad. The Sonoflex icon was placed in the lower right-hand corner of the opening screen page for consistent ease of access. By tapping on the icon, the Sonoflex screen page opens and displays category buttons, called ‘‘contexts’’, that when touched, open to vocabulary screens that are programmed with appropriate Symbolstix picture icons, or photographs (see Appendix 1). When the student selects an icon by touching a button on the screen, computer generated speech for that icon is produced using a gender/age appropriate voice. A single word or a complete sentence may be programmed on each button. For example, when the numeral 4 is touched, the iPad speaks: ‘‘four’’, when the icon with snacks is touched, the sentence: ‘‘I want a snack, please.’’ is spoken. On the home page of the Sonoflex app, the following context buttons were created by the teacher: ‘‘Morning Meeting’’, ‘‘Math’’, ‘‘Reading’’, ‘‘Social Studies’’, ‘‘I want’’ and ‘‘Being Friendly’’ (see Appendix 2 for an example of vocabulary words presented on the context screen).
Measurement Material An observation checklist was developed by the teacher to record the types of communication and prompting levels to
make a response using an iPad. Each type of communication was tallied as a request, response, or social comment, and a prompt score was assigned to indicate the level of support required to assist the student in using the iPad to communicate with an individual (see Tables 2, 3). Median scores were calculated to present appropriate ordinal data based on prompting levels from 0 to 5 for each type of communication.
Research Design and Procedure A single subject, multiple-baseline design with AB phases across settings was used. During the baseline, data were collected during two 10-min sessions 2 days per week for 2–3 weeks. The sessions included one academic lesson (Language Arts) and one recess-time, such as after lunch, to provide opportunities for social comments and requests. During this phase, a session began when an academic lesson started or when the participant was dismissed for a break. The students were verbally instructed, ‘‘Get your iPad and turn on SonoFlex.’’ After accessing the SonoFlex app, they were instructed to select the specific context button. The iPad was positioned lying flat on the right side of their desk without any support. If it was an academic session, the teacher presented the scheduled lesson for that day, and data were collected by recording each of the teacher’s questions as a response and all student responses were recorded without providing any prompts. A minimum of 5 questions were presented. If the student responded,
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initiated a request or made a social comment using the iPad, it was scored 5 as an independent communication. If the iPad was not used to respond, 0 was scored. If it was recess-time, the iPad was placed in the area (usually within 5 feet) where students were taking their break. If they left the area, no reminders of taking the iPad were given. Any responses, requests or social comments using the iPad were recorded. During the intervention, data collection was continued in the same sessions 2 days per week for 6 weeks. Instruction was provided using the least-to-most prompting hierarchy after a 5-s pause. For example, during a Language Arts lesson, the teacher asked, ‘‘Samantha, which word starts the same as ‘car’?’’ The teacher waited for her response, by expectantly looking at her for 5-s. If no response was given, the TA would verbally direct, ‘‘Answer with your iPad.’’ Again, a 5-s pause was provided. If there was still no response, the question was asked again, with the same tone of voice. If no response was given within 5-s, the TA pointed to the correct iPad button, providing a gesture prompt. If, after a 5-s pause there was no response, the question was re-asked. The TA then provided a model prompt by touching the correct button and then gave the student the opportunity to select the button within 5 s. If no response occurred, the question was asked again (still using the same tone as the first time) and the TA immediately guided the student physically to touch the correct button on the iPad. This was followed by an opportunity to touch the button if the student wanted to, by saying, ‘‘Good touching the button to answer, now you try.’’ If the student chose to touch the button on his/her own, social praise was given; if not, the lesson continued without further comment on the question or response. The process was repeated for each type of communication. During a recess session, the student was prompted to request the item using the iPad when observed to have a Table 4 Total number, mean scores and standard deviations of requests, responses, and social comments
Student
particular need, such as staring at a desired toy (request); a social opportunity was provided by starting a game and then saying, ‘‘Whose turn is it?’’ (response) or, after doing a puzzle together, prompting the social comment, ‘‘That was fun.’’ (comment)
Data Analysis A visual analysis of the observation data compared the baseline and intervention for each participant in both class and recess settings, as well as the total number of responses and means. In addition, the percentage of non-overlapping data (PND) procedure described by Scruggs et al. (1987) was used. The guideline recommended by Asaro-Saddler and Saddler (2010) was adopted. This guideline generated a PND score of 90 %, indicating the intervention points exceeding the extreme baseline value for a very effective treatment; 70–90 %, an effective treatment; 50–69 %, indicating some effect, and less than 50 %, a questionable treatment (see Table 4).
Results Table 4 presents the total number of occurrences in each type of communication, and the means and standard deviations across phases. Figure 1 presents individual student’s scores of requests in academic and social settings across the baseline and intervention. Results show that Eric made 13 requests, of those 9 were in the academic and 4 in the social sessions with a mean of 1.67 and .50 respectively. Christian made 12 requests (6 in the academic and 6 in the social sessions with a mean of 1.42 and 1.25); Samantha made 12 requests (6 in the academic and 6 in the social sessions with a mean of 1.79 and 1.72) during the
Phase A Total
Phase B
Total (C)
Mean (C)
SD
PND (%)
Total (R)
Mean (R)
SD
PND (%)
Eric Requests
0
9
1.67
1.37
75
4
.50
.90
34
Responses Comments
0 0
50 9
2.22 1.71
.66 1.17
100 75
27 46
2.01 2.37
.98 .79
83 100
Christian Requests
0
6
1.42
1.78
50
6
1.25
1.71
50
Responses
0
60
3.70
.97
100
21
3.59
1.04
100
Comments
0
10
2.83
1.04
83
58
3.14
.65
100 50
Samantha
C Class, R Recess
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Requests
0
6
1.79
1.90
50
6
1.67
1.72
Responses
0
61
3.38
1.23
100
15
3.50
1.61
92
Comments
0
9
2.67
1.67
75
60
3.32
.42
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intervention, while no one made any requests during the baseline. Although all students increased their requests using the iPad, Eric only made 4 requests out of 12 sessions in recess, generated a PND score of 34 %, indicating a questionable treatment. Both Christian and Samantha made 6 requests in both academic and social settings, generated a PND score of 50 %, indicating some effect of the intervention. Figure 2 presents individual student’s scores of responses across phases. Eric responded to 77 questions (50 in class and 27 in recess with a mean of 2.22 and 2.01 respectively); Christian responded to 81 questions (60 in class and 21 in recess with a mean of 3.7 and 3.59); and Samantha responded to 76 questions (61 in class and 15 in recess with a mean of 3.38 and 3.5) during the intervention, while none of them responded during the baseline. All students increased their responses to questions both in class and recess, especially in class, presenting PND scores of 83–100 % to indicate a very effective treatment (see Table 4). Figure 3 presents each participating student’s scores of social comments across phases. Eric made 56 comments (10 in class and 46 in recess with a mean of 1.71 and 2.37 respectively); Christian made 68 social comments (10 in class and 58 in recess with a mean of 2.83 and 3.14); and Samantha made 69 social comments (9 in class and 60 in recess with a mean of 2.67 and 3.32) during the intervention, while no comments of any students were found during the baseline. All students made comments in both academic and social settings, especially during recess, presenting PND scores of 75–100 %, indicating an effective treatment (see Table 4).
Discussion Our study attempts to evaluate the expressive communication of students with ASD using an iPad with the SonoFlex app in school settings. They were taught to use the iPad with the communication application in learning initial requests, response to questions, and making social comments with a decreasing level of prompts. During the baseline, none of the participants were able to express themselves, and no attempts were made to use the iPad for communication, despite the available access. Same observations were found during the recess, no students used the iPad to communicate with the adults and peers. During the intervention, all participants were receptive to instruction in both academic and social settings. Results showed an increase of their initial requests indicating their needs by touching the icon on the iPad screen with reduced prompts. However, initiating (expressive language) is comparatively harder than responding to questions for
students with ASD (Tiegerman 1993). Comparing to responses to questions and making social comments, the number of initial requests is low. Requests (or mands) are of direct benefit to the speaker, and the motivation to request could be high if the speaker gains access to the requested object or activity preferred (Kagohara et al. 2012). Thus, using highly preferred objects and activities (child-preferred stimuli) to increase students’ requests should be considered during instruction. In addition, continuous instruction with prompts is needed to encourage students to express themselves and initiate their needs which are functional in school. Intensive and frequent interactions (Nind 1999) between teachers and students in both class and social settings should be provided to improve their initiation for communication. Responding to questions is a vital communication skill in the classroom. It allows teachers to assess student comprehension as well as better understand individual needs. During the intervention, all students were engaged in the academic lessons as they scanned the vocabulary words available and touched the screen to respond to the teacher’s questions. Results show that two of the participants (Christian and Samantha) reached the level of independence without prompting (highest score of 5), and the other (Eric) gained scores. These scores not only present the improvement of their communication, but also provide important feedback for the teacher to adjust instruction accordingly to meet all students’ needs. It seems that the use of an iPad strongly supports non-verbal students with ASD to participate in class activities and interact with the teacher. Encouraging social comments from the students promoted their awareness of others in the environment. All participants showed improved skills to make appropriate social comments. The results show that two students reached the highest score of 5 with independence without prompting sometimes, and the other gained scores. All participants made more comments during recess than they did in class. It seems that more opportunities are available for students to make comments on the activities (e.g. games) during recess than the structured class. As indicated by Tiegerman (1993), social situations are very important for autistic students with communication deficits. Thus, the social opportunity should be offered frequently for students with ASD to participate in school activities so that they can continue to learn communication skills and to increase their social interactions with peers and teachers. Further, increasing communication opportunities in social settings will make these students socially recognizable as school members, which will promote their future inclusion in general education classrooms with typically developing peers. In accordance with the findings reported in the previous research (e.g. Kagohara et al. 2012), our study has
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Fig. 1 Median scores of each student’s use of the iPad to make requests during academic and social settings
expanded to an application of the SonoFlex as AAC to support non-verbal students with ASD. The iPad serves as a viable technological aid. Using the SonoFlex application as the communication program not only increased their responses to teacher’s questions in class, but also promoted
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skill learning to other settings such as recess. Our results showed that iPads provided students with ASD an opportunity to communicate with their teachers in class and interact with peers in recess. This opportunity would encourage these students to join with typically developing
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Fig. 2 Median scores of each student’s use of the iPad to make responses during academic and social settings
students in social sessions, such as lunch and recess. Using an iPad is potential for these students to initiate, respond to, and make comments, which will lead them to communicate with their peers in school. Making friends with typically developing peers often is difficult for students with
disabilities, especially for those with limited speech and language skills (Mazurek and Kanne 2010). Individuals with ASD have significantly less frequent contact with friends, fewer friendships, and lower frequency of meeting when compared to typically developing peers (Bauminger
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Fig. 3 Median scores of each student’s use of the iPad to make comments during academic and social settings
and Kasari 2000). Using mobile devices such as iPads will allow these students to carry to social settings to interact with peers using this SGD as a communication tool. This will definitely create an avenue for students with disabilities to communicate with others, learning skills to make friends and build friendship.
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Despite positive results of the study, there are some limitations. First, only three participating students and a short time period of 6 weeks’ instruction may be difficult to generalize the findings to other settings and students. The lack of independent initiation (request) presented by the data may leave the question of whether the use of an
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iPad and associated software (app) is part of a meaningful functional communication system for students with autism. According to Kagohara et al. (2012), systematic instruction consisting of time delay, least-to-most prompting, and reinforcement with a SGD is strongly recommended for students with ASD to learn functional communication skills. Thus, continued intervention with intensive and frequent interactions (Nind 1999) between teachers and students is needed to determine the potential of using the iPad for functional communication, in order for students to achieve more independent levels. We believe that with continued instruction and reduced prompts, the use of an iPad as a SGD will be meaningful and effective. Second, students’ requests, responses and comments were only recorded in two settings, class and recess, though they were in natural school environments. It would be stronger if another setting was included where the students could further learn the communication skills with their iPad as well as their skill generalization in other settings to validate the finding. In addition, the SonoFlex app has some limited features, such as a fixed icon size and all related vocabulary visible on the same screen. Some students would be more successful with larger and fewer icons on a screen, which can link to more specific vocabulary as the student develops proficiency in the use of AAC. Selecting the most appropriate AAC app for each student based on individual needs should be considered.
Implications Communication skills are important for individuals, especially for those with ASD who have little and no functional speech. They are the candidates for AAC approaches to replace or supplement natural speech. AAC provides these students an opportunity to express themselves, present their needs and wants, and interact with their teachers, peers, friends and family members. Currently, there are many AAC devices on the market for families and schools to select, however, most of them are expensive. An iPad with apps may provide an alternative opportunity for these students. To date, many families may already have an iPad in their homes and are already familiar with its use. Using a relatively inexpensive iPad app that can be easily downloaded for students to access may lead to improved communication between children and parents at home, as well as interaction with their peers without disabilities in school. We believe that the iPad for communication purposes for students with ASD will increase as its popularity in our daily lives and its potential to serve as a communication tool in school.
Appendix 1 See Fig. 4.
Fig. 4 Vocabulary Screen for ‘‘Social Studies’’ context button
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Appendix 2 See Table 5. Table 5 Examples of context buttons and associated vocabulary words
SonoFlex context buttons
Vocabulary buttons
Morning meeting
Math
Reading*
Social studies*
I want
Being friendly
Bowling
Monday
0
Emily
Circus
food
My name is
Shoes, size
Tuesday
1
Touch
Fun
drink
Hi
Ball
Wednesday Thursday
2 3
Taste Smell
Juggler Ringmaster
bathroom break
Bye Classmate
Strike Spare
Friday
4
See
Animals
outside
Classmate
My turn
January
5
Hear
Elephant
iPad
Classmate
Your turn
February
6
I
Lion
home
Classmate
Thanks!
March
7
Can
Tiger
Smartboard
Staff
Bathroom
Gym
8
Birthday
Horses
O.T. room
Staff
Drink
Music
9
Red
Website
book
Staff
Snack
Library
10
Loud
Train
Quiet
Staff
I’m tired
Sign Language
Add
Sweet
Ringling brothers
Help
School Name
That was fun!
Sunny
Subtract
Rough
January
yes
My turn
Thank you
Rainy
More
Good
I
no
Your turn
Bus
Snowing
Less
Ran
Like
More, please
Thanks
Break
Cold
The same
Man
Work
Go home?
I had fun!
I did it!
Hot
All done
Van
Yes
Stop, please
Yes
Yes
Yes
Fan
No
I’m good
No
No
No
Yes
I’m sorry
No
Yes
* The words are changed to match the current lesson being taught
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