Some positives and possible warnings about ‘apps’ in speech and language therapy

It appears as though apps are the future of speech and language therapy.In theory I do not have a problem with this as it does make sense to keep up with technology and exploit it wherever there is the potential for it to make our (speech and language therapists’) lives easier, and more importantly, to make a positive contribution to our clients’ development/recovery/rehabilitation.As an illustration of the increasing popularity of ‘apps’, I arrived home today to find the latest edition of the RCSLT’s Bulletin through my door and inside there was an article giving an overview of some of the apps that are currently available for adults with speech and/or language and/or swallowing needs.

Therapy AppsFrom the SLT’s perspective, apps, or more generally tablet computers, would appear to be a sensible investment: they are small yet can store a huge number of different files and applications (i.e. therapy materials); they are touch screen, hence making it an interactive tool which is presumably engaging for clients; they are customisable; if clients see them as being useful, they may then purchase their own hardware and continue therapy independently (which may therefore give the SLT more time to see other clients/patients). Although the hardware itself may be a bit pricey, hard copies of published therapy materials aren’t exactly cheap, so in terms of budgeting, it may be a case or re-directing the flow of cash from buying expensive hard copies of materials which take up valuable shelf space to buying an expensive piece of hardware plus relatively cheap electronic materials which altogether would take up the same amount of space as a single book on a shelf (and a thin book at that).

From the clients perspective, the technology is (presumably) engaging, it can track progress (when this is designed into the app, but probably most importantly it is familiar and accessible – the hardware is publicly available and apps are ‘freely’ accessible to anyone with internet access (although of course you more than likely have to pay for them before you can download – although there are a number of apps which are free to download).It is this final point around the ease of availability that I have slight issues with.

To digress slightly and present some background:Speech and language therapists (in the UK) receive University level training for a minimum of two years in order to gain awareness of the foundations of the theoretical knowledge and practical skills that form the basis of the profession.Upon graduation they must they must then complete a competency framework (usually within 12-18 months) which is signed off by line managers/supervisors in their place of work which confirms that they are able to function as an independent practitioner.Only at this point, is it assumed that a speech and language therapists can independently formulate sound hypotheses based on the results of observation and investigation into the underlying deficits in communication impairment and can develop a course of therapy which aims to work towards goals which remedy or improve the impairment.The point here is that SLTs have developed the knowledge and skills over a number of years which allows them to make expert decisions as to what the more appropriate course of treatment is likely to be.

And returning to the main argument:when apps are made easily available directly to the public, there is a danger that this is ‘cutting out the middle man’ and that clients/patients are essentially choosing their own course of therapy.If someone has difficulty with reading, it is easy enough to do a search for ‘reading therapy’, see what comes up, and to download something which seems like it may do the job.But, as any SLT would tell you, where one person finds one aspect of reading difficult, a different person may find a different aspect difficult – hence, the same therapy may not be suitable for both people.

This is not to say that even if an app is not providing the therapy that an SLT would choose to deliver that it does not give someone much needed practice in the skills that they have difficulty with.However, when delivering speech and language therapy, we are fundamentally seeking to change something about a person’s brain.We may be looking to ‘reactivate’ particular areas of the brain, or, we may be looking to ‘reorganise’ the brain so that damaged areas can essentially be bypassed so that electrical signals can eventually find their intended destinations successfully rather than just simply hitting a roadblock and dissipating into nothing.These ‘reactivation’ and ‘reorganisation’ strategies seek to take advantage of the fact that a person’s brain shows some degree of plasticity (i.e. is receptive to change as a result of some kind of stimulus).

NeuroplasticityAs SLTs we assume that therapy takes advantage of plasticity to achieve positive outcomes.However, it’s also logical to assume that if we adopt an inappropriate therapy then plasticity may give rise to negative outcomes, i.e. may make people worse at something, or in grain a pattern of behaviour which stunts future progress.To give an example from my own experience:During my various studies I’ve spent a lot of time reading about experiments which have asked participants to make judgements on the grammaticality of written sentences (i.e. to decide if a sentence is grammatical or not).As a result of reading so many sentences that are ungrammatical, it is my (subjective) feeling , that I now find it more difficult to pick up on when sentences are ungrammatical if I come across them in other contexts (e.g. if I am doing some proofreading for a non-native English speaker). It is my feeling that my sense of grammaticality has been ‘weakened’ or altered in some way so that I am less sensitive to noticing such things.This is most likely a trivial problem for me as I’m unlikely to encounter situations where my inability to identify whether a sentence is ungrammatical would land me in trouble.However, for a person with communication impairment, clouding an ability to understand speech or writing even further than it already is may have great impact, e.g. imagine listening to someone giving you directions to somewhere where it would be crucial to understand completely and distinguish words like left, right, straight on, and so on.

So before this post turns into an extended essay I’ll just summarise my position so far:1) it appears as though apps will play a large role in speech and language therapy in the future for a number of perfectly valid reasons; 2) I don’t have a problem with the validity of apps per se as the majority of apps, that I at least have come across, do appear to have been designed by speech and language therapists (or at least co-designed) and present therapy approaches that are consistent with what an SLT might do; 3) apps used under direction of an SLT essentially amount to the SLT using the app to present what they would do otherwise except in a different format (e.g. as an alternative to using flashcards, worksheets, little pieces of paper, and so on), as presumably the SLT would have chosen the app after considering what the app does and how this may benefit the individual client; and 4) it is the ease with which apps are available that causes me concern as if unguided by an SLT, patients could be essentially choosing their own therapy, which may not only not lead to positive effects, but which may, in the worst case scenario, have some negative effects.

Now, I’m totally aware that a lot of this post is perhaps based on speculation and I’ve not really cited any evidence (but this is my own personal blog and not an article in a peer-reviewed journal so I make no excuse for this).These are just some concerns that I, and I believe other SLTs, have about the current explosion in the use of apps and tablet hardware in speech and language therapy.To follow this post, I want to move on to considering, from an SLT’s point of view, how to go about appraising an app for use in therapy and for when recommending to clients/patients.

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About chrissp1980
Currently a lecturer in speech pathology in North Queensland, Australia. I'm lecturing in acquired disorders of speech and language and also attempting to enthuse students in conducting clinically-relevant projects using principles of Evidence-Based Practice. Wish me luck!

3 Responses to Some positives and possible warnings about ‘apps’ in speech and language therapy

  1. slptanya says:

    I agree with what you’ve written. When I recently wrote an app, I was conscious of the fact that non SLPs/Teachers (my target audience) may use the app. Fortunately my app is only a PROFILE, not a standardized test – but what if I standardize it at some point? Could parents use it and attempt to make judgements about their child’s phonological awareness skills? Would it still be appropriate for teachers to interpret? Would it negatively impact a child if they work on those skills? (My internal answer is probably not but I can’t be sure).

    Therapy is a different animal altogether. My husband has downloaded some Super Duper apps innocently thinking to play and work towards a skill with our daughter. He didn’t know it was something I have used in therapy or how I used it in therapy. He wasn’t ‘misusing’ the app, per se, but if our daughter had been receiving therapy for that topic, and he downloaded it because it was similar to her SLP’s flashcards – could he then be misusing it?? Possibly…

    I started to consider these ideas when a friend’s sister asked me about intervention possibilities for her son, who is a late talker, while she waited for a full SLP assessment to occur. She mentioned that she had seen lots about PROMPT online and had been trying the techniques with him!! This set off HUGE warning signals for me.

    I’m a trained/certified SLP with many years of experience in treating motor speech disorders and even I am not certified/competent to use PROMPT techniques. She, presumably, found Youtube videos of the techniques and tried to implement them. What en ethical dilemma for PROMPT – who I doubt legally allowed those videos to be posted in the first place – and for SLPs in general. (I advised her to forget the PROMPT stuff until she heard from his SLP).

    It was a wake up call to me that we need to be careful what we share and how we present information as parents WILL innocently misuse techniques and programming or misdiagnose their own children – potentially to their own detriment. But how much responsibility we have and how much responsibility parents/clients have is unclear. I think most people know deep down that they are not qualified to decide these things, but may feel that ‘it’s only speech*, it’s not life and death’ as a rationalization for trying it anyhow.

    I wonder what Drs do about it. Surely this is far more wide-reaching and pervasive in the medical field with the advent of “Dr. Google”….?

    *and by speech, they often mean ‘language’ but that’s a whole other issue ;)

  2. lisaskeeter says:

    My view is that walking or riding a bicycle is never gonna stop other people driving cars. You are better off learning about and taking control of Apps as tools for therapy, in order to able to advise parents on whether to use a particular App, based on experience rather than prejudice. It’s only then that SLPs will be able to influence parent choices which are at the moment highly peer driven as they feel the professionals don’t understand. Remember, most people will feel that something is better than nothing so in the absence of professionally reviewed and researched unbiased evaluations: parents buy anything.
    It worries me that the easiest solution is the one being chosen in the absence of qualified advice. In the old days it was very expensive to access a voice replacement device for someone pre-verbal. Nowadays thanks to 60 minutes – every parent with a child who has not started talking is demanding an iPad and installing a SGD App. In my view they could be missing out on looking at other methods to develop verbal behaviour such as Carbone’s, Bondy’s Pecs based exercises and the magnificent Hanen: More than Words. All of these involve a lot more parent involvement and work than clicking on a download – but they offer a fantastic opportunity to engage and gain the trust and compliance of a learner in order to build on imitation and then vocalisations.
    The App world is very Vendor driven – those with the deepest pockets are getting the most coverage through peer review sites, many of whom are driven by give-aways and freebies – whereas the lesser known low-tech products are overlooked, even by professionals.

    I would like to see one of the Speech and Occupational Therapy associations conduct a wide ranging study, comparing methods with learners and taking data on the most effective, long and short term outcomes, taking into account the carer’s engagement and support.

    But that is just my 2 cents. Disclosure: I developed a non-voca app to keep developing my daughter’s own emerging vocalisations after getting her to communicate via the above – no-tech methods.
    xx

  3. Yvonna says:

    Thanks all for your contributions to this blog. I came upon it by chance as I was looking for possibly a FB page or something where therapists have shared ideas on good APPS. I am a South African SLT and have recently bought an iPad to help supplement my therapy. I have always used an eclectic approach in most of my therapy and are currently using the iPad to consolidate and motivate with my younger or more impaired clients, to present items in a different format to some older clients and as reward for activities either while I chat to parents or write down homework notes or between activities. I too have wondered about what parents are downloading and how they are using the things. I have had a number of clients ask me about APPS – some of which I have needed to research, as I myself don’t really know all of what is out there and am slowly coming across good APPS (and bad ones). I agree with the points, we do need to keep up with technology and be able to offer advice as best we can for specific clients. Parents can go ahead and download their own apps in same manner that they internet search for information and have their kids using all sorts of things in expectancy of a miracle (we’ve all seen it). The thing is, if it were my child… I’d probably do the same. BUT I would like to discuss it with the therapists/teachers managing my case, and I would like them to listen and consider and offer advice rather than poo-poo my attempts at helping my child the only way I know how.

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