Put down that iPad, pick up that PECS box?

Everyday my Facebook feed is littered with the latest miracle stories of how an iPad (or similar device) has helped an autistic child to communicate. Some of those stories are shared from the web, but most of them are from my friends sharing their latest successes with their own child.

Example of assistive technology for communication. Picture by stephanie vacher, via Flickr.

Does the research actually support this miraculous outcry though, and even if it did, should we be getting our kids to put down that iPad and pick up that PECS box? This post is my first effort to answer that question.

First a brief look at some of the existing research. There is a study specifically looking at PECS (Picture Exchange Communication System) as compared to using the iPad to achieve the same ends. It is useful to compare iPads to the PECS system because PECS is a well established communication system for autistic children, with a good reputation. This 2012 study (Flores et al) was a small study, of only five children, but found that those children either improved or had no comparative improvement when using the iPad versus using PECS (ie, an overall positive outcome for iPad use).  Van der Meer, Kagohara, et al. (2012) only looked at four children, and at the iPod versus manual signs, with implications for the use of other assistive technologies. Again, it found positive outcomes for those children involved in the study. A recent systematic review of 15 studies on the use of such devices, also found a largely positive outcome.

A theme that comes through the research is that success using these devices is quite individualised; whether a child responds well to the use of a device is not predetermined by their diagnosis. Nevertheless, it appears to do no harm and potentially much benefit, to give it a go.

But what does “giving it a go” entail? The biggest hurdle for many is simply the cost. We are a two iPad family, but we didn’t pay for either (I won one, my husband got his through work). If we had to purchase an iPad specifically for my autistic son, I don’t know that we could have afforded it (or have chosen to do it). But for those families that can, and those families that have other general reasons to have an iPad in the family, it would seem to be worth a try. I do not think though that it is worth putting pressure on publicly funded services to supply an iPad (or similar device) to a family with an autistic child; the fact is there are still traditional and excellent alternatives available. Similarly (and even more so) I do not think there is strong enough reason to demand a family acquire such a device in order to help their autistic child. Ultimately, any therapists working with a family should be willing and able to adapt to what both the family can afford, and what the child responds best to; that individualism focus is itself what comes through the research.

Where other methods have tried and failed or had limited success, there would be a strong reason to try these new devices, and the sooner the better; early intervention is well documented to make a significant difference in an autistic child’s life.

There are those who seem to rebel against the use of this new technology merely because it is new technology. I have the same leaning; I do not like trying new things as a general rule, and I prefer to stick to what I know best, especially if it already works for me. I think, for people like me, it helps to remember that these technological aides are not about turning known and proven methods on their head, it is about making those known methods more accessible and building on their principles; extending rather than turning away from what works.

My own son had huge communication leaps using PECS. We still have his PECS box, full of laminated pictures, Velcroed backs, sentence strips, and category cards. If we’d had and used an iPad app instead, the primary difference I can imagine for us would have been time and convenience: Access to pictures without having to print them off and get them laminated by his therapist; not sitting on the carpet for hours cutting up and applying Velcro to the back of each picture and sorting them into usable categories; and not having to desperately sort through a box trying to find just the right picture while my son tried to contain his frustration.

Even the process of learning how to properly use PECS, could have been assisted by having an appropriate app; one that step-by-step helps and guides the parent through what to do and when to move onto the next learning level. As was, I had to read manuals and be carefully guided and instructed by a speech therapist when using manual PECS. I don’t think it would be wise or recommended to remove the role of the therapist – you still need someone to guide you to what to use for your child and how best to use it, and to help gauge successes and consider alternatives – but you can’t have a therapist with you all day everyday, whereas an iPad’s app might be able to help fill that gap.

We’ve tried my son on computer programs to assist his learning and communication before, and he struggled hugely with coordinating the mouse to do what he wanted on the screen. The iPad and similar touch devices bypass this common coordination issue, and frankly makes the whole experience more fun for all of those involved (the simple value of “fun” should not be underestimated). Swiping a finger and using a finger to move between and select options, is also highly intuitive.

In a practical sense though, how much sense does it make for a child to carry around an expensive (and sometimes large) device at all times, in order to communicate? The size issue to me is redundant here, because that PECS box and folder under my son’s bed was hardly easy to carry around, and the time required to tidy up and reorganize the pictures as we’d go through the day, was no small thing. As for the price of the device in the hands of a child, I think that’s a fair concern, but outweighed by the value of them having constant access to it, and can be offset by getting older or smaller models of devices that cost less.

Choosing the right apps is no small task, but again that is where having therapists who know the child and are familiar with the options, is always going to be valuable asset. On our iPad we have many apps that have been of no use to my son, and get removed the same day we download them. We also have apps that we’ve used to help our son deal with an issue he’s been facing or to extend his skills in a concerning area. I never just download such apps and leave him to it, I sit beside and help guide him through and discuss arising issues with him, just like I do any traditional forms of intervention (such as using social stories).

An iPad can’t replace all intervention types of course, but that’s not the claim for those who sing the virtues of their use. Occupational therapy, physiotherapy, social skills, as well as communication skills, can all be worked on without an iPad, but an iPad could also be used to enhance and reinforce that learning. It would seem a shame to not use one more option that might be the one that helps that child make a break-through in a skill or in their communication.

When I set out to write this post, I was not strongly in favour of the use of these devices, but the more research I do into their use and successes, it is hard to not become strongly pro their use, for those families that can afford them and are willing to try them. I think there is potential for abuse and misuses of iPads, but the same potential exists in all interventions improperly or ignorantly used (PECS for example has strict guides for what steps to go through and when, it is easy to go wrong and further frustrate and misteach a child using standard PECS without appropriate guidance). Perhaps that is where the danger lies: Perhaps there are too many options and too little guidance when it comes to using the iPad for communication purposes. In that case, it is just an argument for therapists to embrace and acknowledge the role and use of this technology, to help families avoid those pitfalls and to help them get the most out of it: To turn a potential problem, into a very real solution.

I also think therapists should actively encourage families to problem-solve their child’s challenges. In the first few years after an autism diagnosis, it makes sense for the role of therapists to be very heavy-handed, to help parents avoid common errors and to not throw their money away on untested and unproven interventions. But as the years go by the parents must be empowered and encouraged to think-through and find the solutions themselves; the presence and ability to use an iPad does – I believe – extend those options for a family.

My summary then: Research, personal experience, talking to other parents and teachers, and simply thinking through the issues (for what that’s worth), do lead me to see great potential benefits and few dis-benefits in iPad use, particularly as an assistive technology for communication. I can see issues with their use (such as cost, and poor selection and use of apps), but I think the key concerns can be addressed by appropriately supporting a family on how to best use an iPad in their child’s life. I think we need to acknowledge that families are going to try iPads anyway, and be willing to help them make the most of it, and acknowledge further that studies so far are quite positive about the potential benefits. As always, it is essential to take into account the individual child’s strengths and preferences.

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13 Responses to Put down that iPad, pick up that PECS box?

  1. Landru says:

    Our 13-year-old son’s experience with the iPad and Proloquo2Go is variable, and depends on the environment he’s in at the time. He is pretty facile with the iPad and software at school. He’s less facile with it home, because he doesn’t want to be. If he wants to go use the bathroom at home, he points to his PECS book. I’ve seen other kids in his class at school use various assistive technologies, and while it’s not actual science, my observation is that it does, very much, depend on the kid. And on the parent (if I had the energy to force him to use the iPad, he’d probably be more likely to do it).

    I think that for a lot of children, the size and quality of the device matters; our son did not do well with the software on an iTouch, but does much better with the iPad and its bigger icons.

    As to the science…wow, 15 studies with a summed N of 47. That’s not a lot to go with, hmm? But it seems that you’re very much right in that it’s obviously difficult to generalize experiences with specific technologies across behavioral and ability diversity of the autism spectrum.

    Good post, thank you very kindly.

  2. nostromo says:

    Hi, we moved from PECS to P2G running on an iPod touch v4 starting about 6 months ago, due to all the practical issues around PECS that you listed (nice summary BTW). We chose an iPod for portability, an iPad is one thing and we have one, but it’s too big to be with you everywhere all the time, which is what we wanted. Maybe an iPad mini might be the go in the futrue, but for now the iPod is ideal (although potentially the slightly larger v5 might be better, but too pricey for now).
    The way we use it is a simple PECS replacement really. Using Apples ‘Guided Access’ feature on iOS 6 the iPod is locked down to just the P2G application and the options and edit buttons are greyed out, so we have a limited menu olders ‘Food’ and ‘Activities’ for him to choose from that contiain the things he might want, around 10 – 20 Icones in each one (Note: I’m far from an Apple Fan boy and use Android phones myself, but the way the guided access feature is implemented is IMO an example of Apple elegance and simplicity at it’s very best).
    We have a seperate menu for when he is at school so he can’t go around requesting things like ‘Chocolate Fingers’ when at school for example 🙂 .
    He wears the iPod on a retractor fob attached to a money belt type pouch, and he wears it all the time. As he gets more proficient we will add more choices, hopefully Yes and No will be coming at some point, it would be wonderful to get answers to questions..

    • That was an immensely helpful description of the potential application, versatility,and benefits of using iPod technology to replace PECS, the sort of meaningful detail that I simply couldn’t go into since we don’t use the technology in this way in our family. Thank you very much for sharing that, I suspect it will help those who are thinking about whether to use the technology and how to make the most of it.

  3. nostromoswife says:

    Excellent post – we have been through pecs and now onto ipod/ipad with AAC software. I think many SLT’s and professionals don’t really know the best way of implementing these technologies and are having to quickly catch up with the latest apps. My opinion is PECS is still the best way to go initially to teach the social approach side of communication otherwise you may end up with kids pressing buttons on ipads and effectively talking to no one. You’re dead right about the convenience of the ipad – so easy to create new words for him now.

    • Really important point about the social benefit of starting out with traditional PECS (though I must say I see the same potential in traditional PECS for kids who just like to sort and look and play rather than to interact, but yes I can see the problem being heightened by distracting and arguably less-personal technology). Thanks for your thoughtful comment nostromoswife.

  4. Angela says:

    I like the fact that PECS/ photo visuals are more interactive than swiping a screen. You can have a child who physically(motor skill) picks up a card(makes a choice), puts it in their communication board(another motor skill), hears feedback from a “real person” for doing so. Sorry don’t like the whole computer thing-our kids are too obsessed by techno things without using Ipad for yet another possible “stim”. But who am I to say, go with whatever works for you and your family-Visuals the “old fashioned way” worked fine for us with our now adult son who is fabulously verbal can read and write well-good luck to all of you with young ones! Hugs.x

    • Hi Angela. I think it’s really important to hear about concerns with the new technology, those concerns need to be considered and taken into account, so thank you for sharing your concerns. And it’s great to hear how well your son is doing 🙂

  5. nikki says:

    Interesting to hear experiences of kids w speech delay w iPad/pod..
    I am certainly no Luddite, we are very equipped at home, but for my son w asperger’s I have now asked to let me know exactly how much iPad time and use he has at school. I don’t want them to use it as a pacifier and I also do not want them to completely abandon handwriting in favour of a device that he already masters anyway. He is only 7 and I believe there is a fine line between using all these technologies to help them with autism related problems – and just making things easy by completely replacing essential lifeskills and removing human interaction.. That’s a trap we all risk to fall in with devices becoming more and more available to everyone.

  6. Mum to a special little guy says:

    Excellent post. We are currently using traditional pecs with my 6 year old son. Up until age 5, he was pretty much non verbal. He started at a Special School in our hometown Christchurch, at the beginning of Term 2 2012, and the teachers introduced PECS to him, and his speech slowly started to develop. While he can’t have conversations yet, this is still a huge step, and we also started using PECS at home once he had got more familiar and adapted to it at school. He can now say a lot more single words, name colours, say his alphabet and numbers and name most of his favourite things. Any form of communication whether it be Pecs on an IPad or traditional PECS, is better for a non verbal or limited verbal ASD child than nothing at all, a s I know my son used to have really bad meltdowns frequently before PECS was introduced because he had no way of communicating apart from using non verbal gestures like pointing etc.

    • Absolutely right, and so very true about the cause of meltdowns (we saw the same sort of improvements with our son as his communication grew). It’s great to hear about your son’s successes! I hope he continues to have many more. All the best xxx

  7. Janell says:

    I am a behavior interventionist and work with PECS and also an iPad as a communication device. I personally, from experience, like PECS better from a interventionist stand point. I like how with PECS I can truly see if the client is discriminating between pictures with two icons in the book. I can also work on discriminating people. Obviously the client is going to ask mom or dad for a apple or a drink of water instead of me, but if I come to playing tag he would bring me the icon. I do see where the iPad can be liked due to being able to create pictures right then and there as where PECS you have to print and laminate. Also with experience I find the iPad is better for older children having a hard time communicating, as where younger children like to just okay with the iPad. I hope this made sense and gave a different point of view from an ABA stand point.

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