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The other side of the coin: Can apps substitute speech therapy services?

can apps substitute

I am now on my way back home from four very busy days in St. John’s, Newfoundland – Canada! I was invited to attend the CASLPA conference and present a seminar for 3 hours. I have to confess that it is both a bit intimidating and exciting to present in a different country about a topic that while it may seem at first glance that the approach to apps is universal, it turned out to open up my perspective of viewing apps for education by how each countries’ individual social reality and circumstance affects it.

Last week I was very intrigued by a video on YouTube called “Best practices for iPad Therapy” and watched it right before one of my presentations. The USA based speech-language pathologist on the video is also an app developer, and like I have done several times, she talks about the importance of using the apps as a tool to teach a skill rather than as a replacement for therapy. For the last three years I have been strongly advocating for this state-of-mind.

The video was very intriguing as she brings up the temptation that some parents in the U.S.A may face to skip therapy or to not seek speech therapy services now that they have found an app that helps the child learn X, Y or Z skill. After all, this is essentially what they have been hearing on the media: “the iPad is a miracle device for children with special needs.” While it has always been obvious to me that apps are to be used as a tool by professionals, or by parents under the guidance of a speech-language pathologist, I had never even considered that some parents might be using it as a replacement for therapy.

On my presentations I always tell SLPs “The apps are NOT meant to replace you”, you are there to “identify the best way to implement the app guided by best practices, and this is what makes you a professional”. While I mentioned this in my presentation at the National Canadian Conference for Speech Therapists (total attendees approximately 600 SLPs), one of the therapists brought me back to reality: “What if the parent has NO access to any SLP services due to being in a remote area?”. Oh boy! Did that bring back memories from my home country: Brazil.

I guess after living in the United States for eight years, I have also taken for granted the fact that we even have SLPs in school districts. Eight years ago, I was in Brazil calling parents to come for therapy that have been waiting for an evaluation for 3 years! Yes, you heard it right. Now envision that many times when a parent first starts noticing that something is not quite right, the child is about 2 to 3 years old, maybe the parents wait a few months to “give him some time”, by the time they realize their child needs help and tries to schedule service it may take up to 3 years before they actually see a professional.
In my home city in Brazil (the third largest city in the country) speech therapy services are not part of any school services. Private therapies that are covered by some insurance carriers, services in the hospital, or special education institutions are some of the few options available. This is typical for the metropolitan areas in Brazil, which got me thinking… what about the more rural areas????? You get the picture: parents notice that their child needs help, they want to do something about it, but they don’t have the professional available. Now what? Do nothing? Wait?

This got me thinking about speech therapy around the world and given the statistics that around the world more people own a smart phone than computers, could these parents who do not have access to professional be using the apps, which have made educational materials mainstream, to help their child learn?

I have traveled a LOT around the word, been to Africa, Europe, Asia, South, Central and North America; I have over 40 countries under my belt and have seen a lot of service delivery models around the world. I have been to many countries not necessarily as a tourist, but as a professional to observe therapy sessions and learn more about speech therapy, and it amazes me how I have been able to forget and become so distant from the reality outside of the US.

Please, do not think I am not also aware that there are remote areas in the US where children do not have the necessary services, I am well aware of that, hence the explosion of telepractice services for SLPs. Telepractice services in of itself is a concept that few of my good colleagues in certain other countries even know exists. While I was very fortunate to go to college in Brazil, a country that graduates some of the best quality SLPs I have ever met in my career, I also graduated from a country that SLPs have to create their own articulation and picture exchange materials one by one from photographs in a magazine (I DID THIS). At the same time, smart phones have grown increasingly popular and common. Could the combination of these factors: lack of professional services, lack of paper products, high number of smart phones, and affordable educational apps be a reasonable solution for the time being?

Of course, there is yet another side of the issue: most educational apps are in English only. Which is yet another barrier that many non-English speaking countries face. The upside to this is that these educational apps are indeed much more affordable than traditional equivalent materials, which makes them a step closer to those who for sure would never be able to afford any form of non-paper AAC system, or cannot get their insurance to cover any or few sessions.

After thinking very hard on this subject, I am still not sure if it is possible to take a stand on this very controversial subject which can be so far from my current reality, as this is a very theoretical discussion that may not bring any real solutions to those who need it, which is why I feel strongly motivated to do from this day forward. This is not as much simply a professional issue as it is a social issue, it requires more than only SLP knowledge and discussions, but I hope one day we can have a positive outlook and can feel we are all moving in the right direction.

Thanks for bringing me back to reality outside of my own very small SLP circle. 😉 Please be sure to also read the comments and reactions about this post, and to post your reaction as an SLP or parent living this reality.


Comments (8)

Excellent points! The ideal situation is for a client to visit a fully-qualified and knowledgeable SLP who is able to provide skilled services with or without apps and then recommend the appropriate apps and settings for home practice. This therapy service would be covered by insurance or be affordable or be provided during a school day or hospital stay. Unfortunately, this is the reality for only a small percentage of the world’s population, even in English-speaking first world countries. I have worked in the US and Canada, primarily with adults who have suffered a stroke, and know this to not be the norm. SLP services are available in large cities and suburbs, but in remote areas (Canada is full of them!), there may not even be a SLP, let alone one you can access regularly for ongoing therapy.

In areas where there are SLPs, they are usually very busy with long waitlists (as you describe in Brazil). School SLPs must prioritize with consultations, not always direct therapy, as they manage multiple schools at once, while hospital-based SLPs focus on swallowing disorders and have limited outpatient services for communication. Private therapy may be available, but in my area this will cost upwards of $120/hr – not affordable for most senior citizens or parents of children with disabilities.

My average stroke patient gets 6 weeks of inpatient rehab followed by up to 8 weeks of outpatient therapy followed by a lifetime of aphasia. If a product is available for $20 or even $100 that holds the potential to help a family member communicate better, you can be assured that people will be willing to try it. They may chose the wrong product or use it in different ways than the SLP might recommend, but usually the harm done is minimal. They have tried to help, and if they’re keen consumers, hopefully they have used reviews, videos, and other online tools to choose an appropriate app. Apps offer more guided exercises than the flashcards and workbooks that have always been available to the public as well as professionals, and they are not so different from the expensive speech therapy software that has been marketed directly to the public for years.

I’m very grateful to be able to offer my clients affordable apps to make more progress than we could ever make in our limited time each week. Neuroplastic change requires massed and distributed practice that the iPad excels at when used properly. As Internet-savy SLPs, we need to keep making quality advice available to families so they can do the best with what they have to help those that they love.

Many people may tend to forget that the iPad is merely a tool that can help attain a specific set of goals given the right guidance from the right professionals. We have some parents of our kids ask us, a bit worriedly at times, if we highly recommend that they get an iPad for their child. We could only imagine how many families would have readjusted their financial priorities had we said ‘yes’ to them.

All we had to tell them was to try and imagine how things were before iPhones, iPods and iPads came about.

Our training back at the university consisted mainly of this thought: if you were asked to work in a remote province with very few resources at hand, what can you use to do your work? Community-based rehabilitation (CBR) called for the use of everyday objects in a client’s home in order to do a modified language assessment, how to incorporate our speech and language goals in a public elementary school where kids bring their own chairs, how to make our own therapy materials with scraps of paper and a small basket of broken crayons. Yes, we clipped pictures from magazines and newspapers as well. To date we continue to cut labels such as Colgate, McDonalds, Wilkins mineral water and make our own comm boards.

Public awareness work continues: some of us fly / bus to the provinces every month to provide therapy services, give talks, hold seminar-workshops in schools, churches, hospitals, and health centers. Some transdisciplinary work needed to be done with schoolteachers and even PTs and OTs.

The bottomline is that educational apps need not replace actual therapy services. In fact, educational apps need not replace actual communicative interactions. Tools like iPads can add variety, speed, and efficiency to speech therapy sessions. Take away the ‘quality’ factor in these sessions, the best and most appropriate ‘how’ behind how each app is utilized, then the iPad is used as a mere gadget. It doesn’t matter if one simply hands a child an iPad or a picture book: take away meaningful, appropriate and goal-directed support, one loses the bridging between technology and skill acquisition.

(addendum, since I liked Megan’s comment)
Here, therapy sessions cost (converted from the Philippine peso) $12-$17. Average annual family income is around $7,000, with the poorer end of the spectrum earning less than $2,800. Majority can’t afford speech therapy. When outreach programs are done, we create home programs for families and do group workshops. Years pass before these home programs are updated. Because of limited resources both for travel and availing actual services, speech therapy ranks much much lower in many families’ list of priorities.

Thank you for this. I too thought it best to have a professinal SLP and apps as extra…but at the same time I was thinking BUT wait my son does not recieve all the time he needs with a SLP.. I have to fight to get 20 minutes 3 -4 times a month at school, h=e was recieving ST 20 minutes 1-2 times a month. Then there are summers and vacations. I feel, as far as the world goes, fairly well off financially…but as you mention therapy is $$$$$$$$$$$$, then there is PT,OT etc.
So I did invest in an Ipad!Yea!!! BUt now what ????? My mind is boggled with all the apps and web sites about apps. I wish I had an SLP who could guide me. (The SLPS in my area don’t seem to know about apps in their practice.) Anyway Thanks for your site.
mom of Jaime a great 4 year old who has Down Syndrome

Hi Barbara, I agree with you in both senses. I think there is a difference between speech and language. Our 2 autistic children needed a way to communicate first up so I was able to attend a pecs course as a parent, and implement that so they had pictures as their first “language” – a way to get their needs met and reduce frustration. However, when it came to speech, Liam developed his naturally and using behaviorist techniques like Verbal Behaviour we worked on things like “Wh’ questions, Prosody, tenses, pronouns etc using home made materials. However we relied on the assessment of a professional SLT to tell us what level he was at and what to work on next. We just didn’t need to attend sessions as the ABA tutors used the recommendations of the SLT in their program.
With Grace, her speech did not come for many years, she was 6 before she said a single word, and 8 before using words consistently to request things. She will always rely on pictures to support her communication, although with practice she is becoming easier to understand.
However, it is VERY important that Grace now get regular 1-1 sessions with a very qualified SLT with experience in Apraxia as we need to know what is the next sound that Grace should be learning. With this support we can work with the ABA tutors on getting the best approximations of each sound, but we could not accurately assess her core vocabulary development and plan the next step. I can see the benefit of a therapist using one of your apps to record and measure, but you have to have the years of training and understanding of the physical planning involved in sound production to know where Gracie needs to go next.
I’m really concerned by the 60 Minutes/CNN coverage of iPads as “Cures” for autism- looking for an instant fix for what used to be planned, applied, step by step therapy. I feel this particularly with regard to speech generating Apps as I fear that many children who may have learned to communicate independently using sign language or pictures are just having an iPad put in front of them which they are expected to automatically use, without anyone teaching them the fundamentals of interaction. It is like spray on cheese or those awful toaster pastries that require no personal effort but let’s face it – are awful.
Better to have a professional assess and support your child to learn properly, in order to ensure that they learn the steps to independent communication, rather than being dependent on something that speaks for them, but does not teach them to engage.

Very interesting thread and good points made by everyone! As an SLP I am also often overwhelmed by the amount of speech and language apps that are available. I joined multiple list serves and groups in order to try and keep informed. As Lisa commented above apps are not always appropriate for all learners. Multiple factors should be considered but most importantly it is what level of language the child is comprehending. In my practice apps are a fun way to obtain some additional learning of language concepts that I am already teaching in other ways. It’s not a replacement for my teaching but a nice additional support for differentiating instruction to meet the individual learning styles and needs of my students. I loved Carla’s comment:”take away meaningful, appropriate and goal-directed support, one loses the bridging between technology and skill acquisition”. So true!

I definitely agree that the apps shouldn’t replace us and that it’s our responsibility to use them to enhance our therapy! That being said, I do appreciate that there are so many clients that “fall through the cracks” or don’t have the means or resources to get TX. Therefore it would be a good idea that the clients have these “apps” at their disposal to work with–for themselves/loved one!!
However, we don’t know which “smartphone”, etc. they have or can even afford to buy–therefore I feel very strongly that apps S/B available for ALL devices — Especially DROID not just the Apple market!!

Thank you for opening a complex conversation in a thoughtful way.

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