This past spring, Nate was evaluated by a representative of the New England Assistive Technology Center (NEAT), a nonprofit agency that provides access to information, products, and equipment that assist individuals with disabilities. The representative joined one of Nate’s speech sessions to formally assess Nate’s gross and fine motor skills and ensure he could make such devices work properly. She brought two augmentative communication devices for Nate to try – a Go Talk 4+ and an iPad. The iPad was clearly cool. Nate immediately figured out how to turn it on and off and swipe between screens. Though simple and effective, the Go Talk 4+ was the equivalent of a 1980’s cell phone. Large and clunky, it relied on laminated sheets of four PECS images and you needed to record your voice to match each card. Two verbs could be added at the top of the device (i.e. I want & I don’t want) and five sheets of PECS images to be recorded at one time. That provided a vocabulary of 20 words and eight verbs — but the verbs only matched up with the particular sheet to which they were assigned.
Though NEAT has a device lending library, iPads aren’t part of it. We signed out the Go Talk 4+ to try but Nate never took to it. (He did stand on it once just for fun.) Simultaneous to this, Nate started his transition to the public school system. From previous experiences of Nate’s therapists, we knew that this evaluation and the integration of an electronic augmentative communication device into Nate’s therapy needed to occur at least one month prior to his start date in public school. If this didn’t happen, the school system had the right to not support its use. Once we saw how much Nate liked the iPad, Chad and I decided to get one for Nate and I started working with our insurance company to get coverage for it.
Let’s just say here and now that insurance companies can be difficult to work with. You need to know how to say the right thing in the right way at the right time in order to be heard. I started by calling the regular help line; the agent didn’t even know what I was talking about. After going a few rounds, she suggested that we get a pediatric case manager at our insurance company, a service they provide free of charge. The case manager’s job is to help us understand how our insurance company, if at all, can help us address Nate’s needs. So, we got one. And we went a few rounds with her. After telling us how to file for pre-authorization of the purchase of an iPad through our pediatrician’s office (who is incredibly supportive of this venture), the letter came back as being filed incorrectly despite our case manager’s clear instructions. At that point, our case manager did more homework and said that the iPad won’t be covered because it’s not a durable medical good, which is the term you need to chuck around. However they would most likely cover, through our unlimited durable medical goods budget (which doesn’t cover Nate’s orthotics…but that’s another story), the Dynavox suite of devices, which is a durable medical good. The difference? While designed for individuals with autism and other speech, language, and learning disabilities, it’s not magnetic to Nate. And Nate’s therapy team had encountered it and said it was no where near as user-friendly or responsive to immediate situations like the iPad is. The other difference? Including the augmentative communication software and the protective shield, the iPad costs between $675 – $1300, depending on the version /amount of memory of the iPad. Dynavox? It costs between $7,000 – $8,400. You read right. So our insurance company was willing to pay for a $7,000 device but not one that costs $700. Yup. Stumps me, too.
In order to ensure that Nate was using the device prior to the one-month threshold, some other household purchases and needs were put on hold and Nate became the proud owner of an iPad. (Note: after explaining Nate was autistic and the iPad was for him, the “geniuses” at Apple continually referred to Nate as “artistic.” True but, well, not on the money in this particular case.) Nate’s iPad a workhorse: Nate doesn’t get to watch movies or television on it and may only use it for educational and therapy related activities. Nate took to it right away and we’ve even found some unconventional uses for it including reversing the camera so that the iPad becomes a mirror during speech sessions. It’s helped Nate see the shape of his mouth and make adjustments to get sound out.
Since some folks have asked, I thought it would be helpful to run down what equipment and apps we purchased for Nate and what we hope to buy in the future.
Though we could have purchased the iPad 2 and used it with no issues, we went for the most recent version as we anticipate that Nate will use it for many years to come. We went with 32GB to ensure that the augmentative communication software, described below, didn’t eat up all the memory. We also got an Otterbox Defender, a hard protective covering for the device. It comes with a clear cover for the screen, a hard cover for the screen, and a hard case for the iPad’s exterior, all of which protects the iPad if Nate drops it, throws it, or spills something on it. The Otterbox definitely adds some weight to the device but is a must-purchase if getting an iPad for a toddler.
Proloquo2Go by AssistiveWare (iPhone, iPod Touch, & iPad; $189.99)
Pronounced Pro-low-quo To Go (it took us forever to wrap our tongues around that one), this app is the sole reason why we got an iPad for Nate. It is augmentative and alternative communication software that gives Nate a voice. An electronic version of Nate’s PECS, this program allows us to immediately respond to situations and help us figure out what Nate wants, as it can incorporate images from the iPad’s camera roll, a giant library of PECS images, or from a live photo taken with the iPad camera. It also lets Nate participate in social situations, such as making a selection off of a restaurant menu and placing his order with the waitress. We investigated the software online, read reviews, and also saw an inspiring demo of Proloquo2Go, and the use of the iPad with autistic children and adults, in a 60 Minutes segment online. (It’s totally worth watching. You might even cry because it’s so awesome to see a 20-something nonverbal guy suddenly be able to speak!)
Proloquo2Go is used in Nate’s therapy at school both in speech and regular therapy and operates similarly to his PECS binder. A menu of PECS are provided. Nate clicks on the “I Want” picture, which goes up into the sentence strip at the top of the screen. He then clicks on the image of what he wants (“jelly beans”). Each “card” is given voice when selected; once he’s formed his sentence, Nate clicks on the sentence strip and Proloquo2Go repeats the whole sentence (“I want jelly beans”). Separate folders/PECS boards can be established for different therapists, activities, or locations and picture cards are easily created, deleted, stored, or interchanged.
The software is intended for lifelong use, effective for toddlers like Nate up through adulthood so it comes with a suite of male and female voices that reflect both age and locality. You can down load English-speaking voices with American, Australian, British, and Indian accents, all of which can be modulated to match the tone/pitch of the user’s (imagined) voice. New last month is the voice named Josh, which is the recorded voice of a real, honest-to-goodness kid. We are over the moon about this release as we had been using the Ryan voice for Nate, a fellow that sounded a bit like a synthesized Mr. Moviephone. You can go here to hear the difference and learn how they captured Josh’s voice. (The creators said the hardest part was getting the kid to sit still during the recording process!) This is an incredibly expensive app but it was worth every dollar and the license includes downloads for both the iPad and iPhone so it may be accessed at any time.
As an example of how well Nate uses this system, here’s a video of his coloring adventures this past week. Clearly, he needed more stickers!
After we got Nate an iPad, we had to teach him how to use it. His first instinct was to smack the screen or use the palm of his hand, none of which are effectively understood by the device. Both of these apps taught Nate how to apply a light touch to the iPad screen while having a great time. The Bubbles app is pretty straightforward: when you drag your finger on the blank screen, a trail of bubbles appears. With the light touch of one finger, you can pop each bubble. This app taught Nate the cause and effect of pointing at the screen and also introduced the “click and drag” action. Butterflying is similar: you can use a stock photo or one of your own as the background and then select a butterfly to appear in the picture. They fly and land all over the photo; when you double tap on each one, they fly away for good. If you want more, you select a breed of butterfly and then single tap on the screen. Nate likes an iPad filled with butterflies, which he rearranges (click and drag) and sends away. Even though he’s mastered the motions now, Nate finds both of these apps to be quite calming and enjoys a quiet moment popping bubbles or making butterflies fly.
Duck Duck Moose (iPhone & iPad – $1.99 each)
Nate is ga-ga for their three song-related interactive stories: Wheels on the Bus, Old MacDonald, and Itsy Bitsy Spider. The song is sung throughout the book (in Itsy Bitsy Spider, you can change the language of the voice and instrument of the music as I learned when Nate suddenly made it start singing in Italian….) and each page has a series of hidden interactions. The spider’s hat bounces up and down, the window can open and close, flowers grow out of the flower pot, the squirrel on the roof collects and counts nuts, etc. Nate adores returning to every page to make things go and flipping through the pages in search of undiscovered interactions. This company, which was highly recommended to us by Nate’s lead teacher/therapist at school, also makes other apps, which I’m sure Nate will enjoy when he’s older.
Tropisounds (iPhone & iPad – $1.99 each)
Nate blazes through the Tropisounds “wood” puzzles, the whole family of which can be found at the bottom of this link. The younger versions, including Wood Puzzle, Wood Puzzle Easter Colors, Halloween, and Christmas, all of which Nate has, are simple matching pieces puzzles. However, the Wood Puzzle First Years is the one Nate enjoys most. They’re layered puzzles that require a specific sequence of actions in order to work. For example, you can’t get the boy and girl dressed without first putting in their hearts or you can’t complete the penguin puzzle without first putting the fishies in his belly. To find all of the puzzle pieces, Nate has to scroll in the bar at the bottom of the screen so it keeps him on his toes and very entertained. For both the simple and layered puzzles, there are verbal reinforcements for each action. In the simple puzzles, shapes are labeled (square, circle, oval) by a toddler’s voice when placed in the correct spots. In the more complex app, a toddler’s voice reminds you about the order of action if you’ve forgotten (“Try the heart first!”) and raises you up when you’ve completed a puzzle. (My favorite is when the toddler hollers out at Nate, “You’re a genius!”) There’s also a suite of other Tropisounds apps that we’ll visit once Nate outgrows these puzzles.
Custom Lock Screen HD Lite (iPad – Free)
Because Nate’s school has iPads for in-classroom use, we didn’t want Nate’s iPad getting mixed up with someone else’s iPad. So we use this app to create a custom lock screen using a photograph of Nate and his name (which we’re working on getting him to recognize). It allows you to take any picture in your camera roll, add text to it, and save it as your “lock screen,” the screen that you see when you enter your password. Super simple and effective.
There’s one app we haven’t bought yet but plan to – it’s called Scene and Heard. It’s a social story app that allows you to take photographs, create boxes around specific items in the picture, and record a story linked to that box. For instance, if I took a picture of Nate’s bedroom, I could draw boxes around his bed, Hobbes, and his closet. The stories could describe “This is where Nate sleeps,” “This is Nate’s best friend,” and “This is where Nate’s clothes are stored.” It has so many possibilities for introducing new environments to Nate in advance of encountering them and is much easier to manage than printing out a book, writing text, laminating the pages, and then reading it to Nate over and over again. The software is pricey – $49.99 – but there is a lite version that is free so you can see how it works.
Where to Find Good Apps
There are a bunch of other apps on Nate’s iPad, including ones that take data on his performance, many of which we downloaded for free. We keep tabs on Smart Apps for Kids, which has both a website and Facebook page. Their Facebook page makes announcements about the free app of the day; their website also includes reviews and links to apps by subject and by appropriateness for toddlers, pre-school kids, and those ages 6-8, 9-11, and 12 and up.