Autism Spectrum Disorder and Assistive Technology

What Do We Know About Autism Spectrum Disorder (ASD) and Communication?

Development of communication skills among children with autism does not follow so-called typical
patterns. Children with ASD appear to learn differently than other children and frequently have
difficulty with spoken and written language expression. Children with ASD may not speak at all,
they may speak just a few words, or they may speak but what they say doesn’t make sense in
the situation. Children with ASD may have difficulty understanding spoken language – even if
their hearing is “fine”. They may also not be able to understand gestures, body language, and
tone of voice that convey subtle differences in meaning. Children with ASD often demonstrate
difficulties with overall motor planning. The motor planning involved in speaking – coordinating
the mouth, lips, tongue and facial muscles – is extremely complex and requires sophisticated
motor planning ability. Similarly, the motor planning involved in writing or using sign language is
complex and can prove challenging for children with ASD. These factors complicate
communication for children with ASD.

How Are Communication Barriers Addressed with Children With ASD?

Despite the communication challenges ASD can present, an assumption should never be made
that nonspeaking children with autism don’t or can’t communicate, or that they will never
“speak”. An array of Alternative and Augmentative Communication (AAC) approaches can be
used to enhance, expand and develop communication skills. The three primary forms of AAC used
with individuals with autism include unaided approaches (signs; gestures), “low tech” picture-
based systems (for example, Picture Exchange Communication System -- PECS), communication
books and boards and speech generating devices (SGDs). In addition, a variety of other
assistive technology, such as portable word processers, can support effective written expression.

What Are Speech Generating Devices (SGDs)?

Speech Generating Device (SGD) is the term given to the hundreds of voice output devices
commercially available that are designed to provide an effective means of verbal communication
for individuals whose “natural speech” is not functional for them. Other terms sometimes used to
describe these items are “voice output communication aids” (VOCA) or augmentative
communication devices. SGDs range from simple, single message devices with less than a
minute of speech output to highly complex, computer-based systems capable of storing or
generating virtually unlimited numbers of messages. Some SGDs use recorded human speech
(digitized). Others use computer-generated speech (synthesized) and some of those have text-
to-speech capacity (as words are typed into the system, they are “spoken” by the device).
Graphic symbols, most commonly in the form of line drawings, are used to represent messages,
which are activated by finger, headstick or other method touching an area on the device that
corresponds with the desired message. SGDs have either a static display where input for stored
messages is fixed (like buttons or keys) or a dynamic display (like a touch computer screen)
where the input can be changed quickly and often. For reasons unrelated to their effectiveness,
utilization of SGDs lags far behind the use of other AAC systems (e.g. PECS and sign language) as
an intervention option for students with ASD.
Do AAC systems deter speech development in children with ASD?

NO – It is erroneous to believe that if a child is given a communication device, in particular a

SGD, it will hinder speech development. This seems to be based on the faulty assumption that
using the AAC system is “easier” and the child will “give up” on the more difficult task of
developing speech. Research and clinical experience indicate this is not true. Humans tend to
use the most effective means of communication available to them to interact with others. It is
usually much more efficient for a child to use speech and/or vocalizations if possible to
communicate than to formulate a message using an augmentative communication system.

AAC will NOT interfere with speech development. AAC systems in general have been shown to
not interfere with speech development for those individuals who have the capacity to develop
natural speech, and there is evidence that AAC can facilitate speech development for some
children. Research suggests that once an AAC system is introduced and an effective means of
communication is available some children improve their language skills as well. In any case,
appropriate AAC interventions will almost ALWAYS improve communication.

While research is inconclusive about how AAC actually supports speech development, some
believe use of the AAC system reduces pressure on the child to develop speech as the sole
communication mechanism and that results in greater speech production skill development.
Others postulate the AAC system supports continued development of language skills and
conversational skills, which translates into increased speech production.

Because of fears that AAC will impede speech development, there is a mistaken belief that AAC
should be introduced only after giving up all hope on development of natural speech. This should
not happen! By exposing a child to years of failed communication attempts, we increase the
likelihood that other effective but unacceptable means of communicating will be used (e.g. excess
“behavior” like throwing a chair to mean “I’m bored with sitting at this table”) or communication
will decrease altogether. For children with ASD, AAC should not be viewed as a wholesale
replacement for natural speech, but rather as a supplement or alternative means to provide
functional communication access as natural speech development is pursued. The choice is NOT
BETWEEN AAC or “natural” speech, but how to use AAC – including SGDs, unaided, and low tech
approaches - to maximally support development of natural speech and effective communication.

Why Use SGDs ?

Although sign language and low –tech picture-based systems (including PECS) have established
records of success with students with ASD, there are a variety of features that make SGDs
compelling options as part of an AAC intervention for children with ASD. SGDs provide speech
output, which is more readily understood and accepted by other communication partners (e.g.
family members, community members, professionals, peers, etc.). Because the output is spoken,
communication partners don’t need to learn special skills like how to interpret pictures or gestural
messages. SGDs also provide the child with an auditory model of what the message sounds like
when it is “spoken”. Speech output can transcend distance, e.g. can be used for telephone
communication, or when the listener cannot make eye contact with the child (e.g. when mom is
driving and the child is in the back seat).

High end, dynamic screen devices come pre-loaded with extensive symbol arrays that can be
organized with little effort and in many instances new page sets can be developed on the fly. Low
tech, static devices generally use overlays that can easily be changed and, increasingly, more and
more companies are utilizing bar code technology that improves the ease of use. Many SGDs are
designed to be portable and durable. Implementation and observation by speech language
pathologists, special educators and other professionals has uncovered additional positives in
support of SGDs including:
 The “techie” nature of SGDs is appealing and motivating to children with ASD. Use of
SGDs may be less stigmatizing than PECS and other AAC systems.

Children with ASD frequently prefer visual stimuli. SGDs use a visual medium, frequently
a dynamic visual interface, making them effective for children with ASD.

Most SGDs require only simple motor movements to operate, bypassing the motor
planning difficulties that some children with ASD evidence.

SGDs often can serve to preempt difficult behaviors since they provide a quick, consistent
means to express needs and wants.

When Should AAC Be Considered For Use With A Child With ASD?

As soon as readily possible! All children with ASD deserve access to an effective and efficient
communication system including a full range of AAC options that can be used to support positive
cognitive, social, emotional and behavioral development. That includes consideration of SGDs.
Simple SGDs such as the single message BIGmacks can be used at roughly the same time that
non-disabled children begin to speak. More advanced devices can be introduced as appropriate
based on the child’s development. The first years of a child’s life are critical to language and
speech development and children with ASD need the same opportunities available to non-disabled
children -- language rich environments and encouragement to express their thoughts and needs.

Are There Any Cognitive Prerequisites A Child Must Have To Use SGDs?

There are no cognitive prerequisites for using an SGD. It is extremely difficult to assess the
cognitive ability of some children with ASD. Thus, it is important to assume cognitive and
communication potential. An SGD provides a framework for the development of language and as
a result, regardless of the current cognitive/language level at which a child with ASD functions, an
SGD can support and expand that existing language. When a child with ASD is able to
communicate, his or her cognitive abilities can become more evident. This can change the
perception of parents, peers, teachers and the child himself.

Are There Any Specific SGDs For Use With Children With ASD?

Any SGD can serve as a first step in exploring communication with children who have ASD.
Evaluation usually proceeds through the identification of device features that will “match” the
needs of the child. Features include the number of messages that can be stored, the system for
retrieving messages, the approach to combining units of meaning (e.g. to generate new
messages), the system used to represent vocabulary, the potential of the device to “grow” as the
child’s language develops, the flexibility of the device (e.g. to run other software programs), etc.

How Are AAC Companies Addressing the Unique Needs Of Children With ASD?

Visual Scene Displays, Built-In Digital Cameras and hardware design are some of the recent
trends that companies have been introducing to assist children with ASD communicate. Several
digitized and synthesized devices now provide visual scene displays. Traditionally, SGDs have
utilized a grid screen approach that divides the screen or page into various target areas. Visual
scene displays portray events, people, actions and objects against the backdrops in which they
occur or exist, helping to provide context and meaning. Active areas, or hot spots, within the
scene provide links to specific words, phrases and messages for communication.
A second recent development is the provision of built-in digital cameras. The traditional text and
symbols used to represent language can sometimes be a barrier to acquiring effective
communication. Digital photos and video clips provide concrete representation and eliminate the
need to learn new symbols. They also simplify and make the communication process more
natural. The ability to take digital images and quickly embed them into new communication pages
shows significant promise to help children develop new language skills, prepare them for new
situations and help add context to their world.

What other assistive technology (AT) can be used to support children with ASD?

Children with ASD can benefit from a variety of assistive technologies in addition to AAC such as:

Assistive Technology Description Used To Address

Portable Word Processor Keyboard with small LED screen Poor fine motor or motor
planning skills for writing
Talking Word Processor Writing software programs that Poor fine motor, motor planning,
provide speech feedback cognitive, or combination
Text To Speech Program used to convert text Poor reading comprehension,
Software from print to audio formats decoding, fluency, etc.
Visual Assistants Graphic symbols sequentially Behavior issues and develop task
Electronic/Non- laying out events/activities (may completion/focus and language/
Electronic Organizers also have auditory cues) communication skills
Headphones Earphones that cancel Auditory overstimulation issues
extraneous environmental noise
Assistive Listening Speaker worn transmitter and Deficits in attention and listening
Systems listener worn receiver or near comprehension and auditory
placed speakers overstimulation issues

How are good decisions made about assistive technology for children with ASD?

Making decisions about assistive technology (AT) is similar to making decisions about other
services for children with any disability. A team approach is necessary with members
knowledgeable about the child, his/her strengths and limitations, the activities, tasks, and
environments in which he/she function, and the range and scope of potential AT options to
address specific needs. The team should have access to AT to use in structured device trials in
the environment(s) in which the child will be using the technology (e.g. home, school,
community, etc.) This allows for device trial data to be comparatively analyzed; in particular
different device features and functions can be compared to determine which best addresses the
child’s functional needs. Using this analysis, the team can make cogent decisions about AT
acquisition. Teams and professional providers conducting device trials can borrow a full range of
AT from ETC, a short-term device loan program operated by Missouri Assistive Technology
(MoAT). Additional information about borrowing can be found on the MoAT website,
www.at.mo.gov or by contacting MoAT at 800/647-8557 or [email protected].

Professionals who specialize in AT can provide teams with valuable support in decision-making.
For some types of AT, funding sources require evaluations by specific providers (e.g. Missouri
Medicaid requires approved sites provide the evaluation and recommendation for AAC funding;
Medicare requires a licensed speech-language pathologist evaluation/recommendation for AAC
funding; and many private insurance plans require a physician prescription for certain types of AT
funding.) Teams should be familiar with and access specialty resources as necessary to support
decision-making and to secure AT funding as required by specific sources. See the MoAT website
for more information about evaluation sites and funding sources for assistive technology.