iPad Use for Children With Apraxia

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Parent and SLP observations exploring the impact

Technology continues to intersect all facets of our day-to-day life, including our work with clients. Without a doubt, iPad technology and the constantly growing and changing array of applications for the management of those with communication disorders are now firmly rooted in the field of speech-language pathology. Yet, the benefits of such applications as perceived by clients, caregivers, and clinicians are not known. Information about the experiences and reported outcomes of those with communication disorders using iPad technology may not only support their use, but also guide future experimental investigation of the effectiveness of iPad technology.

To date, there are no empirical data in peer reviewed journals on the use of iPads in treatment for individuals with speech sound disorders, though there is emerging evidence to support their use with individuals with communication disorders such as children with autism.1 Specifically, children with childhood apraxia of speech (CAS) benefit from multisensory treatment with a variety of biofeedback and cues.2-5 Additionally, children with CAS may benefit from augmented communication to facilitate expressive language use. Integrating iPads in therapy, at home, and at school with the guidance of a speech-language pathologist can address these goals with a motivating and fun tool.
The study was part of a larger investigation that examined the impact of the iPads for Kids with Apraxia Pilot Program initiated by the Childhood Apraxia of Speech Association of North America (CASANA) as reported by the participating caregivers and clinicians. Following an extensive review process, CASANA provided 40 children (32 boys and 8 girls with a mean age of 6.9 years [SD=3.0 yrs]) with childhood apraxia of speech (CAS) an iPad free of charge to support their treatment. The iPads were equipped with Speech-EZ Apraxia Program6 and Proloquo2Go, though clinicians and parents were permitted to download and use any additional applications they wished.

Earlier analyses of this dataset7 indicated that parents and SLPs qualitatively reported positive perceptions and experiences with iPad technology. The aim of this present study was to quantitatively identify changes in children’s ability to communicate and participate in daily activities following the implementation of iPad technology.

Methods 

A combined quantitative and qualitative group pretest-posttest design was used to study the short-term outcomes of children with childhood apraxia of speech (CAS) as reported by their families and clinicians after initiating the use of iPad applications at home and in therapy. Forty parents and forty SLPs participated in this study. Four of the SLPs used the iPads minimally due to concerns of the child’s school regarding potential loss or destruction of the device (n=3) or due to behavioral concerns with the child’s ability to use the device appropriately (n=1).

All parents and clinicians completed quantitative surveys two weeks or less before receiving the iPads. All 40 parents and 32 of the SLPS completed the posttest measures six months after initiating their use. The participants also responded to questions regarding the experiences associated with using the iPads within phenomenological approach. All questions were presented via www.surveymonkey.com.

The Focus on the Outcomes of Communication Under Six8 was included in the pre- and post-test measures and is the instrument focused upon in this component of the investigation. The fifty items of this questionnaire (see below) were based upon the framework of the International Classification of Functioning Disability and Health-Children and Youth (ICF-CY). The FOCUS primarily reflects the Activities and Participation Factors of the ICF-CY. Recently, the inter-rater reliability and construct validity of this tool was established.9-11



Results
 

Interestingly, the parents’ and SLPs’ average FOCUS scores did not significantly differ at the time at pretest (t=1.28, p=0.20) or at posttest (t=0.52, p=0.60). Though as predicted, scores did significantly increase from the time of the pre-test to post-test for both clinicians (t=19.14, p<.001) and parents (t=13.06, p<.001). Thus, both parents and SLPs reported significant increases in functional outcomes six months following the initial use of iPads (Figure 1).


Thus, children were observed to have increased functional communication skills six months after beginning to use iPads including increased participation in a variety of activities and increased ability to be understood by others. Inspection of individual items indicated that both sets of respondents rated items regarding interaction with unfamiliar adults, independent communication, and clear speech as notably impaired (Figure 2 and Figure 4).

Positively, the child’s ability to get along with peers, willingness to talk to others, asking for things, etc. was reported by parents and SLPs. Figure 3 displays the mean scores on the FOCUS items for parents and SLPs related to the all items that asked about interactions and communication with peers, interactions and communication with adults and general communication items (e.g., My child uses words to ask for things) before and after the use of iPads. Descriptively, parents and SLPs reported greater concern with the children’s communication and interaction with adults compared to their peers. Their mean scores were highest for items that reflected the children’s overall comfort with communication.


As displayed in Figure 4, the children’s speech became more clear six months after iPad use according to SLPs (U=390.5, p<.01), though parents did not report a significant increase in speech clarity (U=596.5, p=.07).

These data are congruent with previous analyses of the same parents’ and SLPs’ experiences and perceptions related to iPad use for their children and clients with CAS.7  For example, parents and SLPs consistently reported that the iPads were beneficial in facilitating more accurate speech production and improving overall communication. Likewise, parents and SLPs described that the children were highly motivated by and engaged with the iPad and speech production related applications and that the children were immediately competent with the device. The respondents also stated that the iPad allowed for a wide variety of therapy contexts and increased home practice. As might be expected, the most frequently reported obstacles for iPad implementation was managing the child’s compliance and impulse to use the iPad as a “toy.”


Overall, these previous qualitative findings along with the current quantitative data collected via the FOCUS questionnaire align with the statement by one participating SLP who stated that the iPad “served so many purposes.therapy mode, communication device, social skill developer and reinforcer” and another who stated, “the iPad definitely motivated the student to engage in therapy and produce the targeted syllables/words-much more so than using traditional articulation cards.” Additionally, the overwhelmingly positive outcomes and experiences of children with CAS selected to receive these devices in the pilot program led to a continuation of this remarkable iPads for Apraxia Program. To date, CASANA has distributed over 400 iPads with cases to children with CAS.

Discussion

Functional changes in the communication skills of children with CAS during activities and participation with others were observed by their parents and SLPs within six months of using iPads at home and in therapy according to their responses on the FOCUS questionnaire. These findings are similar to a recent study that demonstrated the ability of the FOCUS to document change following only 7-10 hours of therapy.9 Additionally, this study further promotes the need to value the experiences and functional outcomes of those affected by speech sound disorders and their surrounding community, rather than solely monitoring speech sound accuracy.12,13Incorporating parents and other family members in all aspects of the clinical management of children with CAS is particularly vital for their communicative success.2 The collective findings of this investigation not only demonstrated the benefit of iPads in facilitating practice outside of a typical therapy setting, but also elucidated parental concerns, perceptions, expectations related to their children’s experience of living with CAS.

Limitations of the current study include the inability to separate the effects of iPad use in therapy and in communicative interactions from other therapeutic interventions, activities, and general maturation within the six month period. However, responses to open-ended questions indicated that the introduction of the iPad was often the perceived catalyst for change, at least in the SLP setting. This study also does not provide empirical data on the effectiveness of a specific therapy program provided via a tablet. Future research will benefit from including the clients as respondents as well.

The current findings indicate that iPad technology may be a particularly useful tool for extending speech sound intervention outside of therapy settings, yet always under the guidance of a SLP. Likewise, integration of iPads and appropriate applications in therapy and home may lead to more seamless practice and support of communication, leading to meaningful and functional improvements for children with speech sound disorders. Lastly, these data, combined with the continued growth of such tablet technology, strongly point to the need for a study of efficacy of using applications in the treatment of CAS and other SSDs.


References

  1. Lorah ER, et al. Evaluating picture exchange and the iPad as a speech generating device to teach communication to young children with autism. Journal of Developmental and Physical Disabilities. 2013; 25:637-649.
  2. American Speech-Language-Hearing Association. Childhood apraxia of speech. www.asha.org/policy.
  3. DeThorne LS, et al. When “Simon Says” doesn’t work: Alternatives to imitation for facilitating early speech development. American Journal of Speech-Language Pathology. 2009;18:133-145.
  4. Hammer DW. Treatment strategies for childhood apraxia of speech [DVD] Pittsburgh, PA: CASANA. 2006.
  5. Preston JL, et al. Ultrasound biofeedback treatment for persisting childhood apraxia of speech. American Journal of Speech-Language Pathology. 2013;22:627-643.
  6. Carahaly L. The Speech-EZ Apraxia Program. Foundations Developmental House, LLC. 2010.
  7. Rusiewicz HL, et al. SLP & parent-reported experiences related to iPad use by children with childhood apraxia of speech. www.apraxia-kids.org.
  8. Thomas-Stonell N, et al. Predicted and observed outcomes in preschool children following speech and language treatment: Parent and clinician perspectives. Journal of Communication Disorders. 2009;42:29-42.
  9. Thomas-Stonell N, et al. Measuring communicative participation using the FOCUS©: Focus on the Outcomes of Communication Under Six. Child: care, health and development. 2013;39:474-480.
  10. Thomas-Stonell N, et al. Validation of the Focus on the Outcomes of Communication under Six outcome measure. Developmental Medicine & Child Neurology. 2013;55:546-552.
  11. Washington K, et al. Construct validity of the FOCUS© (Focus on the Outcomes of Communication Under Six): a communicative participation outcome measure for preschool children. Child: Care, health and development. 2013;39:481-489.
  12. McCormack J, et al. The impact of speech impairment in early childhood: Investigating parents’ and speech-language pathologists’ perspectives using the ICF-CY. Journal of Communication Disorders. 2010; 43:378-396.
  13. McCormack J, et al. My speech problem, your listening problem, and my frustration: The experience of living with childhood speech impairment. Language, Speech, and Hearing Services in Schools. 2010; 4:379-392.
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About Author

Heather Leavy Rusiewicz, PhD, CCC-SLP

Heather Leavy Rusiewicz is assistant professor, Department of Speech-Language Pathology, John G. Rangos School of Health Sciences, Duquesne University. The author would like express her gratitude to CASANA and to the families and clinicians that participated in this investigation.

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