Clare Hudson, Speech and Language Therapy Manager, St Paul’s Hospital and Special School gives a clinical perspective on the wide array of technologies available

Not so long ago I was getting some help from my fourteen year old niece to download something onto my phone. As I struggled with the task she said, ‘Maybe it was easier when apple and blackberry were just fruits.’ I’m sure she heard these words from some wiser person, but at that moment I wouldn’t have minded if they had been just fruits again! However, new meanings of such common words (not to mention clouds no longer being just for rain) reflect the technological world we live in. While some might be daunted by this contemporary world, for individuals with autistic spectrum disorders (ASD) and their families, recent technological advances have already opened doors to new experiences and opportunities and in time have the potential to open many more.

This article provides a brief overview of Alternative and Augmentative Communication (AAC), describes the use of a voice output communication aid (VOCA) with a young man with ASD, and gives a clinical perspective on the decision-making professionals and families face with the wide array of technology available.


Communication Matters organisation (2013) suggests that AAC refers to a range of strategies, equipment, systems, methods, and techniques used by people who have impairments of speech, language or communication. These approaches may be unaided (not requiring anything external to the body—e.g., use of eyes, facial expressions, gesture, signing) or aided (requiring something external to the body—e.g., symbols, communication boards or books, and technology-based systems such as VOCAs). Aided systems can further be divided into high-tech (those aids requiring a power supply, (such as VOCA) and low-tech (those aids that do not require a power supply e.g., pictures, symbols). AAC has been used to support the communication skills of individuals with autism for many years and various approaches have been shown to be successful, including VOCAs (Brady 2000), pictorial systems (e.g., Carr and Felce 2007) and sign language (e.g., Tincani 2004). Over the last number of years, technological advances have led to an increase in popularity and interest in the use of high tech AAC to support individuals with ASD. The visual nature of the information provided by this technology, which is more concrete and permanent than spoken words alone, supports receptive and expressive communication for many people with ASD.

A clinical perspective

A number of years ago, when working with an adolescent called Simon, I first got involved with high tech AAC in the form of a VOCA. Simon has a diagnosis of ASD. At the time he had no spoken output, but he had relatively good functional literacy skills (ability to read and write short sentences), and interacted with others for a very limited range of reasons and about a limited range of topics. There was a mismatch between Simon’s expressive language abilities (seen in his ability to write short sentences) and his use of this language to communicate with others. At the time, Simon frequently engaged in behaviours that were harmful to him. Simon had in the past used low tech AAC systems such as the Picture Exchange Communication System (PECS), but the team working with him wondered whether a VOCA could support Simon to communicate more effectively, ultimately reducing the frequency of his self-injurious behaviour.

Following observations of Simon in a number of environments, the data collected was analysed and a hypothesis was drawn up as to the function of his self-injurious behaviours. In addition, communication opportunities were set up in Simon’s natural environment to allow consideration of what motivated him to communicate. A multi-faceted intervention plan was put in place which included the following elements:
■ Provision of a VOCA to match Simon’s abilities and needs, allowing him to be more specific about the messages communicated,

■ Manipulation of Simon’s physical and social environment to create more frequent opportunities and reasons for him to communicate,

■ Specific training for Simon’s communication partners in the use of ‘augmented input’ (Elder and Goossen’s 1994, cited in Mirenda 2001; Cafeiro 2005). This approach involves the communication partner simultaneously touching the corresponding symbols to his/her words as they are spoken. Thus a model for use of the VOCA is provided.

■ Integration of the VOCA into Simon’s everyday activities, as this has been shown to lead to the most successful outcomes (Beukelman and Mirenda 2005).

Figure 1 Line graph showing the frequency of Simon’s self- injurious behaviour and communicative interactions before and after the intervention (T1 and T2 respectively)

‘SIB’ denotes ‘Self-injurious behaviour’ and ‘CI’ denotes ‘Communicative interactions’ ‘Time 1’ is data collected before the intervention and ‘Time 2’ is data collected after the intervention
‘SIB’ denotes ‘Self-injurious behaviour’ and ‘CI’ denotes ‘Communicative interactions’
‘Time 1’ is data collected before the intervention and ‘Time 2’ is data collected after the intervention

The intervention lasted one month (the length of the loan period for the VOCA at the time) and involved staff training, modelled sessions by the speech and language therapist and carry-over sessions by the staff working with Simon. The outcomes included:
1. A substantial decrease in the frequency of Simon’s self-injurious behaviour and a concurrent increase in his communicative interactions (see Figure 1)
2. An overall increase in the frequency of communication functions across settings (Figure 2)

Figure 2 Bar chart showing the frequency of Simon’s communicative interactions across a range of communication functions in both school and residential before and after the intervention

’School 1’ and ‘Residential 1’ denote data collected before the intervention during observations in school and residential unit respectively ‘School 2’ and ‘Residential 2’ denote data collected at the end of the intervention during observations in school and residential unit respectively

3. Qualitative and quantitative changes in Simon’s interactions with his communication partner (see Table 1). The duration of the interaction at the end of the intervention is seven turns (four of which are Simons) from a baseline of three turns. Simon maintains the topic on each turn without having to depend on a question prompt from his partner.

Interaction Before Intervention (T1)Interaction After Intervention (T2)
Partner: “Yes. At ten o’clock you’re going cycling. In fifteen minutes there’s cycling” Partner: “Something about home...”
Simon: (Bangs his head off the table three times)
Simon: “Tuesday” (Simon turns a and looks at his communication partner)
Partner: “Simon’s going home on Tuesday”
Simon: “2.20” (Simon turns and looks towards the author)
Partner: “Yeah. You’re going home on Tuesday at 2.20- And who are you going to see there?” (Opens ‘family’ page)
Simon: “Mam”

The words in bold denote those that were spoken using the VOCA in Simon’s case and using the VOCA for Aided Language Input by the partner

Throughout the intervention Simon showed excellent ability and potential in terms of navigating around the VOCA and moving from screen to screen (operational competence), and in his ability to understand and combine symbols to create messages (linguistic competence). As may be anticipated for some individuals with ASD. given the inherent social impairment, Simon had greater difficulty managing conversations (social competence) and managing social situations (social domain).

Interaction between the four skill areas named above supports the development of communicative competence in AAC use. Simon’s difficulties in managing conversations and social situations were seen, for example, in a visit to the shop where he used the VOCA to tell what he wanted in the absence of a shop assistant close by to hear him.

Based on the study findings and observations of Simon, he was funded for an AAC-specific hand held device. When I met Simon most recently, he had also moved with the technological times. He was using a handheld media device for the general population (iPod touch) with an AAC-specific app (Proloquo2go) as a communication aid. Like us all, Simon uses a number of different modalities when communicating with different people. He often finds that with communication partners who know him well he can efficiently and effectively get his message across by pointing, leading and vocalising. Simon’s preferred topics of interaction have remained similar to those of his pre-VOCA days. The VOCA has, however, provided him with a channel to effectively communicate with un- and less familiar communication partners, and to communicate about novel needs that arise in new situations.

This case study has its limitations from a research perspective: the speech and language therapist was Simon’s communication partner at Time 2 data collection, rather than Simon having the same communication partner as at Time 1. Demands of one task changed from Time 1 to Time 2. The study did provide, however, a clinical experience of the potential gains for one individual with autism through the introduction of a VOCA, combined with specific training to communication partners. For Simon, an improvement in his quality of life was evident.

Decisions, decisions …

Like many other professionals, over the last number of years I have had to up-skill in the area of technology for use with individuals with ASD. On many occasions I have felt like I was playing catch-up with the children and families I work with in terms of keeping abreast of all new technological advances. Whilst challenging, this is also a very exciting time. It seems that current devices and apps on the general market have great allure for many individuals with ASD. This may be due to the highly visual nature of the information presented, the dynamic screen or the inherent predictability of the effect of pressing a specific button, or something else ….This technology is relatively affordable, easy to carry around and socially very acceptable, and it is therefore becoming more widely used.

Within the Aladdin’s cave of apps and devices, the task of deciding what to use can seem overwhelming. At this point let’s get back to basics—to key principles of AAC that will support the decision-making process to determine what is best suited to a specific individual, for now and for the future. These principles include:
■ Clear identification of the purpose of the technology/device or app.

■ Devices and apps are available to support education, leisure skills, communication, independent living, social skills and employment. Determine whether the focus is to support the individual’s language and communication skills, or to teach numeracy or literacy or, indeed, to provide an activity in which the individual can engage independently for a period of time (e.g., a game or a film).

■ Matching the capabilities and needs of the user/individual to the features of the device/app

Specialised assessment will gather information on the needs of the user in the following domains: sensory, physical, social, cognitive, linguistic and communicative. Assessment will also consider the characteristics and needs of the communication partners as well as environmental demands. Identification of key features of the device such as size, durability, volume controls and maximums is essential in the matching process (user to device matching).
■ Identifying and including an appropriate instructional approach as part of the intervention package, as this is required to enhance communication.

■ AAC users and communication partners benefit from support and training to use specific techniques and strategies to maximise the benefits and effectiveness of AAC.

A best judgement can be made between the individual and device or app when the assessment is complete. It is then time to give it a go. It may be that a device or app is found not to be suitable immediately, but experience tells us that the door may not be shut forever. A match between the individual and the device may be made at a later date (adapted from Howard et al. 2012).

Final thoughts

We live in exciting times and it seems that the technological revolution has come at a good time for many people with autism. While the latest technology does not provide the cure or the answer to autism, it may open doors for people with ASD to increase their independence, social access, and to enhance their quality of life. While we await further research findings into the effectiveness of the use of technology with people with ASD, we know from a clinical perspective that when technology is applied appropriately to address a specific issue, it can be very effective. The key to success is in professionals and families working together to find the correct match. For now, armed with knowledge of the key principles of AAC, I am ready to embrace the new apples and blackberries of this world and see where they lead…

The case study outlined in this article was completed as part of an MSc LACIC at the University of Sheffield.


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