Apple's iPad and 3rd party app developers are revolutionizing Augmentative and Alternative Communication (AAC) technology and how people access it (not everyone is happy). The March newsletter edition of ATPN takes a look at iPad's claim to AAC, and the territory it never really set out to colonize (articles are also posted here).
Part One: Proloquo2Go Brings AAC Mainstream
The app story for AAC starts in April of 2009 with the release of Proloquo2Go from AssistiveWare, the first software application for AAC to run on a mainstream mobile device. The computer version, Proloquo, had been around since 2005, developed by AssistiveWare Founder and CEO David Niemeijer. Niemeijer, who was an agricultural and environmental scientist in the Netherlands, got drawn into assistive technology in the 1990s when a close friend became quadriplegic (the AssistiveWare logo was designed by this friend with the use of a Head Mouse and AssistiveWare software). With the release of the iPhone--and Apple's decision to allow 3rd party app developers for its products--the pressure was on Niemeijer to develop the 2Go mobile version.
From the outset, Niemeijer's goal was to create an app that could be fully operational, including all necessary hardware (iPod Touch) for about $500, vastly undercutting the AAC dedicated device market (which can run more like $2,500 to $8,000). This accomplishment would turn out to be a game-changer in the industry. AssistiveWare has not released how many apps it has sold, but with 460+ ratings on iTunes alone, and the quake in social media it has provoked, its impact is clear. Indeed, at a presentation at the Assistive Technology Industry Association (ATIA) Orlando conference this past January, one special education director confessed (while standing before a screen displaying a student using Proloquo2Go) "It's wonderful how the iPad has enabled so many students to have a communication device who otherwise couldn't get one (because Medicaid wouldn't approve it)."
Today there are dozens of apps for AAC (for iDevices and beyond), ranging in price from free (or nearly so) to Proloquo2Go's now hefty-seeming $189.99 price tag (and others which exceed it). Apple made it easy to market and sell apps on iTunes, and now it can feel like everyone and their great aunt Martha has come up with something. The apps range in quality, features, and goals, and the need to sift, compare, and feature-match them for individuals is spawning new Web sites, charts, and tools.
In January, ATPN had a chance to interview Niemeijer at the ATIA as well as listen to the enthusiasm and anxieties expressed by speech language pathologists (SLPs), occupational therapists (OTs) and others about iPad. Indeed, the iPad (and apps in general) was a dominant conference interest with sessions ranging from "AAC Device Decision-Making: 'Apples' (iPads/iPods) or 'Oranges' (Traditional Devices)" to "The iPad AAC Phenomenon: What's Not Being Said." ATPN found Niemeijer at his booth--and was startled by the weary forthrightness of this Dutchman wearing a backpack. It turned out to be a great opportunity to get his take on all the chatter.
ATPN: Proloquo2Go has been so successful. What do you think about the concerns out there that iPads will put dedicated devices out of business?
David Niemeijer: [With Proloquo2Go] we wanted to reach all the people who do not get funded. So we had to go at a significantly lower price point. And I think that's what happened, that we've been serving the 95% of people who need this and don't get funding. It may have affected sales of traditional devices, but I don't think that much.... I think we've really opened up a new market rather than competed in an existing one.
ATPN: There's a concern, too, that iPads are in schools and so they're being used for AAC because it's so much cheaper and so there's pressure to make this work.
DN: I think there's some truth in that, but I think that in many more cases those schools were not buying any device [before the iPad]. Or it was there but generally [students] wouldn't use it because it was too heavy for younger children or too ugly for older children. So I understand the concern. But my impression is very much that this is filling an area that was not being filled. My impression is that Proloquo2Go or other apps are replacing light tech not high tech in schools. There are some schools that may be going to this instead of Dynavox, but I think it's more that many schools are now providing a service that they were supposed to provide that they were not providing, rather than that the right solution is being driven out by the wrong solution.
ATPN: At a workshop here an SLP mentioned there was concern that it would be bad news if Medicaid started covering iPads and iPods for AAC because it would make it so much harder to get anything else funded. They were advising professionals to get in front of the issue now by writing into Statements of Medical Necessity exactly why an iPad won't work if the request is for a dedicated device.
DN: I think the system just needs to change because it's a wasted opportunity to serve more people. But then there are the concerns that the system will decide this is a way to save money rather than serve more people, which is why we're not getting involved in it [the Medicaid approval issue]. Plus the concern that people will be pressured into making this work when there's a better solution.
ATPN: Which is really the big anxiety at the conference about iPads, the pressure SLPs are under to make iPad work because parents are buying them, and then finding they don't know how to make it work for their kid.
DN: Basically the rules of the game have changed. First it was the professional who was in control, the professional was the one who provided access. And now the parents have control. They can go ahead and make a decision [and buy an iPad]. And you know sometimes of course they come home with the wrong stuff. There are definitely issues with that. But with how the old system worked there was basically a small percentage of all the people who could have benefitted [by AAC technology] who were benefiting. And now a much larger percentage of people are benefitting.
Something I've learned in the last few years is that there are so few people specializing in AAC. There are states where there's like a handful of people for the whole state! Which means that special educators, OTs, SLPs, many without an AAC background are being confronted with, "Oh we bought this for our child. Can you help me?" Or the school says "We need this for our students, we saw 60 Minutes" [60 Minutes did a story last October on the iPad for communication and learning]. I think there are many more AAC users every year. I think more of them are using apps on iPads than going for traditional devices right now. And that means where there was already an imbalance between the number of AAC experts and number of AAC users, now that imbalance is growing very, very rapidly.
ATPN: One SLP mentioned that another issue with apps is that people choose them without understanding how language develops or with longer-range goals in mind. She felt core language was poor with Proloquo2Go and people go furthest with a system like Prentke Romich (PRC).
DN: And then why not bring PRC to iPad? Because in this country training and support has to be built into the cost of the device. And then there are people who may prefer another solution! Proloquo2Go 2.0 will address the core language issues [due out in April]. But I also think different systems work for different people. We use SymbolStix. There are people who say Dude! You have to use PCS! Or it has to be Widget! Yet there are kids and adults all over the world managing to do something good with all of these systems.
I'm an outsider to all of this. I'm not trained as an SLP or an AT specialist, but to me it's a kind of ongoing war between people who have strong ideas, professionals with strong opinions based on a lot of insight, when in reality there are good things about everything and everything is a compromise. Technology A might get 5% more out of someone than Technology B, but I don't think it's the technology that's the bottle neck [for people to have effective AAC]. That's just a distraction. The bottle neck is the fact that there are not enough professionals who have the knowledge to implement and teach AAC in an effective way. To me, when I go around places, everyone is struggling with that. And I think that you can take an app like Proloquo2Go or a PRC device/Minspeak system and give it to an experienced (versus an inexperienced) professional to work with, and I think it's that professional who is going to make the difference, not the device, not the language system.
And I think there will still be cases where a dedicated device is better, or a particular language system is better, but what I'm hearing from schools that I visit and preschools that I visit is that [Proloquo2Go] is making a huge difference for the majority of children they try it with, and that some preschoolers are actually going to regular ed. now because they have a communication system when they are two or three years old whereas in the past they wouldn't get something like that until they were like eight or ten, and they would be in special education, and that's a huge cost to society and to these individuals, not getting the opportunity early on to develop. So the impression I'm getting is that in many cases it works.
ATPN: David, thanks so much for all your insights!
Part Two: Prentke Romich's Service-Centered AAC
Prentke Romich (PRC) is a traditional AAC company that has been doing business for 45 years, has a history of supporting and nurturing AAC research, and provides videos on its Web site that demonstrate individuals with complex communication needs enjoying spontaneous exchanges with the use of its devices. PRC's Unity Language system use symbols with multiple meanings (Minspeak) that sequence to create grammatical sentences and are arranged predictably to make use of an individuals's motor memory (for intuitive faster recall). In these ways PRC is different from what is currently available on mainstream consumer mobile platforms.
Recently PRC released the first in what it advertises will be a series of apps for iPad. To better understand how the apps revolution is impacting this pioneer dedicated device company, ATPN interviewed PRC's Director of Clinical Applications Russell Cross.
ATPN: What is the PRC strategy for developing these apps?
Russell Cross: At this point our aim is to provide apps that we hope will support people who are currently using our technology and using the Unity Language. The aim is to use that portable tablet platform as a teaching tool, as an electronic book, something to help you learn what your are doing with the device. So our target is to use the tablet technology as a way of distributing teaching and therapeutic materials.
ATPN: So your target is people already using PRC products?
RC: In the main, yes. Though we actually have heard that people have been downloading and using it with non PRC products and the reasons that sort of works is because what we're focusing on is language and vocabulary. And although the app has pictures and icons that are specific to the PRC product, the language isn't. So people are using this as a language development tool. And the same goes for the AAC Language Lab which is our Web-based location where we have lots of info about language and language development, where we have teaching ideas, and while it's geared towards people using PRC products, we do know there are a lot of people going there and adapting materials for whatever they're doing.
ATPN: Your approach to language--using symbols that can be used in specific ways to express grammatical meanings--is so sophisticated. And there's a learning curve to it, and so it's different from apps which use symbols with one meaning and/or text. I'm wondering what your reaction is to the apps and iPad phenomenon? And what the implications are for your company?
RC: This is a fundamental issue within AAC technology. Language is one of those things that we all use so intuitively that we imagine it is very easy. But the reality is that language is very complex, and when you look at it piece by piece, we do have to take some time to learn it, and translating that into technology or mechanical forms is actually a lot more complex than one might think. And the notion that you can download an app with 25 buttons and that will give you all the language you need because it's dead easy to do, is simply nonsensical, because that isn't the case. [Editor's note: see "Apps Buyer Beware" on the apps phenomenon subsequent to Proloquo2Go's release...]
ATPN: But for some the relief of being able to communicate at all looks like such a victory particularly when you haven't had access before.
RC: You're absolutely right because what you're putting your finger on is the notion of what is your measure of success? And the measure of success is very different in the world of mainstream consumer devices versus the world of the traditional AAC system. Sometimes we refer to this as "consumer AAC" or "over-the-counter AAC," because it's a bit like what we do if we have a headache. We don't necessarily go to see a brain surgeon or neuro surgeon, we go to CVS and buy some pills... and we have a whole selection to choose from, and either it works or it doesn't. ... And if your measure of success is previously my kid could say nothing, and now I download this app for $10 and he can say "I want a drink," and "I love my dad," and if he can do that very quickly, that may be a fit, depending on your measure of success.
For traditional AAC the measure of success is to have some form of interactive spontaneous conversation. We want our clients to be able to do what you and I are doing now, having a conversation over the phone. But for other people, that seems either too far away or not something they've ever considered. Because clearly there are people buying iPads and apps who have never come across the concept of AAC before. And when they find something that works, then that's great! I'm not going to quibble with that. But if it doesn't work than how do you help people look at other alternatives? And our job has always been to try and help those folks for whom regular technology does not work. Now, of course, with the new tablet devices, there are regular technologies that do stuff that they didn't used to do.
ATPN: Right, your field has just narrowed because of what the mainstream is now offering up.
RC: What we have to be very careful about is thinking that, oh my goodness, we're losing people here! But actually there's still all these other folks who need our stuff, who come to us and say, "Look, don't stop making your--whatever--because I can't use an iPad, I can't use it. People try to give me an iPad and I can't use it." So our job is not to compete with an iPad or Android or Samsung Tab. We can't build a 7 inch tablet for $500, that's never going to happen! But we can build devices that have specialized requirements and that build on the notion of help with service and support.
And so that's what we're doing with eBooks and the apps and the Language Lab [Web site] and specialized trainings, we're putting more of a focus on support. SLPs, they're literally having people knocking at the door, iPad in hand, saying What do I do? People have downloaded a solution that they wanted to work, nobody's doing this for a bad reason, everybody's doing this for a very good reason, they wanted to help their kid, and then when they get it, it works at a certain level, and all of these things will work for some purposes, but typically what happens is you want to do something else, you want to move on. And I think, that next question of who should I talk to, is an area where PRC and other AAC companies can be looking at. Can we offer help and support to people on AAC implementation?
ATPN: Where will I go next?
RC: Absolutely and folks really do discover that their kids tend to be smarter than people have thought, and then they say Oh this is great! However, what I've just got has taken me to a certain level but I want to move on from here and this thing that I currently have won't do that for me.
ATPN: Will PRC ever provide its system for iPad?
RC: Technically there's no reason why that couldn't happen. The bigger question for most of us mature AAC companies is how do we do it and make it so that people can get help and support. You could probably make an app that would do this, but there's still that question of who do I now talk to and where do I go for help? If we give it away for free, there will be no one to talk to.... Many of the AAC companies are built as much on service and support as they ever were on technology.
Learn more about the stages of language development at PRC's AAC Language Lab Web site.
