There’s an issue here which has been building up in my mind for some time so I wanted to put my thoughts down. I hope they might be of use and interest to both researchers in the field, and to parents or practitioners supporting people with autism. But I must emphasise these are my considered, but subjective opinions, rather than objective, research-based findings.
Of the 350 or so apps listed on the Autism Speaks website as targeted at people with autism, the largest proportion (almost 25% when I counted in January 2013) are for communication. In many cases this means an app which uses visual symbols on screen combined with audio to act as a ‘voice’ for the user. They essentially turn the iPad (or other tablet or phone) into an augmentative and alternative communication (AAC) device. In addition, I think it is accurate to say that many of these AAC-apps are fairly highly priced by app store standards – for example £129.99 for Proloquo2Go and £139.99 for Speak for Yourself . This isn’t to say these apps are overpriced as they contain vast libraries of symbols and audio, but it does mean deciding whether to buy one is a bigger decision than trying the latest pre-school game for £1.99
Initially, my knee-jerk reaction was against this kind of communicator for people with autism who are pre-verbal or non-verbal. My logic was highly influenced by approaches such as PECS (Picture Exchange Communication System). As I understand it, one of the fundamental principles of PECS is that the communicative act should require interpersonal interaction and joint attention. A child needs to do more than just select the right symbol to represent what they want (e.g. a picture of an apple). They also need to identify a communication partner, gain their attention, and hand over or at least show that symbol. For a non-verbal person with autism, it is understood that the main barrier to communicative success lies not in the physical domain, but in the social element of communication between two people. So what PECS does is provide a non-speech way to practice communication between two people, revealing the function of communication (e.g. as a way to get an apple) and thus scaffolding learning of spoken language.
My instinct when it comes to audio communicators is that these provide not a route to learning to speak, but an alternative to speech. And indeed traditionally they have been mostly developed for and used with those whose barrier to speech is physical (e.g. people with cerebral palsy) rather than social. An audio communicator does so much of the work for you – the child presses a button, or on-screen image, and the app speaks for them. In a single act, the app attracts the attention of anyone in earshot, and transmits the required information. So the child can make their needs known without having to directly interact. And therefore AAC apps bypass the difficulties believed to be central to autism, instead of addressing them.
However, recently some conversations and a bit of reading have made me feel this perspective might be unfounded. First, I have encountered anecdotal evidence that people with autism have started to use speech by echoing their AAC apps. This isn’t always entirely positive – in our own Click-East RCT one parent reported that her son had learnt new words by copying the app but that they weren’t necessarily useful in everyday life (she gave the examples ‘turtle’ and ‘seashell’) and that he was using an English accent when the rest of his speech was distinctly Scottish! This account makes me wonder whether learning from an app that uses a synthetic voice could produce similar problems. But new words are new words, and in another example, a parent commented that her son had started using the phrase “Can you help me?” when he had a problem, which she believed he was copying wholesale from the app’s prompt script. So one positive effect of using an audio communicator might be learning of new words or phrases via the common tendency among people with autism to echo speech.
Another reason for my initial anti-AAC stance may be rooted in the oft-used description of people with autism as ‘visual learners’. In the communication domain, I wonder what we mean by this. Is the reason so many non-verbal people with autism benefit from a visual timetable or a communication support like PECS really because of a predisposition to learn visually? Or is it more simple – humans can produce audio content at will and instantly. Communication is rarely a strong suit for people with autism and so in this area, additional support might be required. So we take the existing audio (our own speech) and add a visual support like PECS or Makaton. Why would we add extra audio? But when we switch from an emphasis on comprehension of what others say to thinking about production of their own speech, providing an audio communicator and facilitating auditory learning makes a lot more sense.
Two other issues are pertinent here I think. One is the distinction between pre-verbal and non-verbal. While I have no desire to write off an individual’s ability to learn new skills across the lifespan, we might think differently about how to support communication in a three-year-old who has a vocabulary of a dozen words, and a thirty-year-old with the same vocabulary. In the latter case, providing an alternative to speech makes a lot of sense whereas for the young child we might still want to focus on promoting spoken language. Though – as noted above – it might also be that one route to learning new speech is to use audio models.
The final point to raise is how this fits in to our attitude to autism as a construct. I wrote above that one weakness of AAC apps is that the “child can make their needs known without having to directly interact“, as if this were a weakness. I might as well write that the problem with a wheelchair is that a person “can move around without having to walk”. If our goal is to accept autism as an alternative way to be in the world, and to include in that embrace people who experience profound challenges to ‘fitting in’ as well as those whose abilities allow them to ‘blend’ if they so desire, then creating alternative routes to communicate which don’t require such intensity of social interaction is essential.
I’m hoping to find a space sometime soon to follow this blog with a comparative review of a number of communicator apps available for both Apple and Android devices so watch this space. And cross your fingers for me too! – I’m interviewing next week for a Beltane Fellowshipwhich will buy out some of my working time to focus on these sorts of activities. Just imagine – being paid to blog and tweet – heaven!