Augmentative and Alternative Communication

ISSN: 0743-4618 (Print) 1477-3848 (Online) Journal homepage: http://www.tandfonline.com/loi/iaac20

Using the Choiceboard Creator™ app on an iPad© to teach choice making to a student with severe disabilities Jennifer Stephenson To cite this article: Jennifer Stephenson (2016) Using the Choiceboard Creator™ app on an iPad© to teach choice making to a student with severe disabilities, Augmentative and Alternative Communication, 32:1, 49-57, DOI: 10.3109/07434618.2015.1136688 To link to this article: http://dx.doi.org/10.3109/07434618.2015.1136688

Published online: 02 Feb 2016.

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Augmentative and Alternative Communication, 2016 VOL. 32, NO. 1, 49–57 http://dx.doi.org/10.3109/07434618.2015.1136688

RESEARCH ARTICLE

Using the Choiceboard Creatorä app on an iPadß to teach choice making to a student with severe disabilities Jennifer Stephenson

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Macquarie University Special Education Centre, Institute of Early Childhood, Macquarie University, NSW, Australia

ABSTRACT

ARTICLE HISTORY

This paper describes an intervention to teach the use of the Choiceboard Creator app on an iPad for choice making to a student with autism, severe intellectual disability, and challenging behavior. This app provides flexibility in the number of pictures and blank distractors displayed, produces voice output, shuffles the picture arrangement after each activation, and makes the selected picture more salient by enlarging it once it has been selected. The effectiveness of the intervention was explored using a multiple baseline across three settings. Pre- and post-assessments of the student’s ability to select a picture given the spoken word or the object and to select the object given the spoken word or the picture explored the further development of picture skills. The student learned to use a display of three pictures in free play, a display of two pictures in morning circle, and a display of five pictures at morning tea.

Received 17 August 2015 Revised 9 December 2015 Accepted 16 December 2015 Published online 28 January 2016

Introduction For children with severe disabilities, including autism spectrum disorder, who have little or no spoken language, an aided augmentative and alternative communication (AAC) system using graphic symbols can be a viable option for those who are developing symbol skills (Beukelman & Mirenda, 2013; Ganz et al., 2012). Graphic symbols may be presented as pictures on cards, or in a communication book, or on an electronic device such as a dedicated speech-generating device (SGD), or on a touch device such as a tablet or iPodß1 using an AAC application (‘‘app’’). Interventions using tablets or iPods have been shown to have positive effects on the communication skills of individuals with autism and other developmental disabilities (Alzrayer, Banda, & Koul, 2014; Kagohara et al., 2013; Stephenson & Limbrick, 2015). There is some evidence to suggest that some students with autism spectrum disorder prefer touch devices (iPod touch or iPadß1) over hard copy picture use or the unaided option of manual sign, and that performance is better with the preferred strategy (Achmadi et al., 2014; Couper et al., 2014; Gevarter et al., 2013). It is also generally established that teaching requesting or choosing as an initial use of graphic symbols is a viable option as it allows the student to express wants and needs and to acquire preferred items and activities (Reichle, York, & Sigafoos, 1991). Studies to date of the use of iPads or the iPod touch have focused on requesting (see for example,

KEYWORDS

iPad; augmentative and alternative communication; speech-generating device; severe disability; autism spectrum disorder

Couper et al., 2014; Flores et al., 2012; Gevarter et al., 2014; Lorah et al., 2013; Sigafoos et al., 2013, van der Meer et al., 2013). The use of an iPad as a speech-generating device for AAC has several advantages, such as affordability, availability, and use of a mainstream technology (Cumming & Strnadova, 2012). In addition, the larger size of the iPad compared to the iPod touch is an advantage for some students (van der Meer et al., 2014). The large number of AAC apps available allows for flexibility of use of the tablet, depending on the app being used. To date, however, only a small number of the many available apps have been used in research studies. Most studies have used the Proloquo2GoÔ2 app (Alzrayer et al., 2014), but other apps, such as PECS Phase IIIÔ3 software (Ganz, Hong, & Goodwyn, 2013), Pick-a-WordÔ4 (Flores et al., 2012), GoTalkÔ5, and Scene and HeardÔ6 (Gevarter et al., 2014) have been used in a few studies. Students may use SGDs and graphic symbols effectively for specific functions and tasks without being fully symbolic communicators. Students who are symbolic communicators use graphic symbols for comprehension and production, for a range of functions and in a range of contexts including making reference to the past and future and to objects not present (Mineo Mollica, 2003). In order to use a tablet app as an SGD for beginning symbolic communication, users must develop basic picture skills that allow them to discriminate between symbols

CONTACT Jennifer Stephenson [email protected] Macquarie University Special Education Centre, Macquarie University, NSW 2109 Australia 1 The iPadß and iPodß are products of Apple Inc., Cupertino, California. 2 Proloquo 2 GoTM is a product of AssistiveWare, Amsterdam, The Netherlands. 3 PECS phase IIITM is a product of Pyramid Educational Consultants, Inc., Newark, Delaware. 4 Pick a WordTM is a product of PUSH Design Inc. 5 Go TalkTM is a product of Attainment Company, Inc., Verona, Wisconsin. 6 Scene and HeardTM is a product of Therapy Box, Ltd., London, UK. ß 2016 International Society for Augmentative and Alternative Communication

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and relate the pictures displayed on the device to the objects they represent (DeLoache, 1995). Tablet apps have features that may facilitate this learning. The voice output produced when a picture is activated may support learning of the relationship between spoken words and graphic symbols (Alzrayer et al., 2014; Schlosser & Sigafoos, 2006), particularly for learners who are developing verbal comprehension of object names. Many apps allow the use of more iconic pictures, such as photographs of specific items, which may support the learning of picture use for beginning users (Stephenson, 2009). They also offer many options for the size and arrangements of the pictures to be learned, thus allowing for interventions to begin with only one or two pictures displayed, this number gradually increasing as progress occurs. In addition, some apps offer features that may make the relationship between object and picture more explicit. The app used in the study reported here (Choiceboard CreatorÔ7 Version 1.10), as well as providing voice output and the capacity to use photographs as graphic symbols, also responded to the touch on a specific picture by enlarging that picture to fill the whole screen while providing voice output, thus making the link between the spoken word and a specific graphic symbol more salient. An additional feature of this app which forces learners to discriminate pictures based on their content in order to use the correct picture for the item they want, and not on the position of pictures in a display, is that the positioning of the pictures is shuffled after each activation. Once students have acquired basic picture skills and the general understanding the objects are represented by pictures that resemble them (DeLoache, 1995), this feature would not be required. Indeed, for competent picture users consistent positioning aids fluent use (Beukelman & Mirenda, 2013). In their 2012 review, Ganz et al. classified interventions to teach aided AAC to individuals with autism spectrum disorders as child-led, naturalistic, or teacher-led, all of which have been successful in at least some contexts (Ganz et al., 2012). Childled strategies, frequently used to teach use of picture exchange, begin with the student initiating an interaction by indicating the desire for an item. The teacher may display the item and may control access, but does not give a verbal prompt or cue and massed trials may be used (see, for example, Ganz et al., 2013). Naturalistic interventions are similar to child-led, but use natural activities as the intervention setting and the teacher does not totally control access to items. No studies using this approach to teach the use of tablets as SGDs could be located. In teacher-led interventions, instruction takes place in a contrived context and the child may not demonstrate any desire for the item to be requested. The teacher may initiate by indicating to the child that choices are available (see, for example, Gevarter et al., 2014). In both the child-led and teacher-led interventions, determining if requests or choices are valid, that is, that they reflect a genuine preference or need, can be problematic. Where only one item is available or where use of a generic request symbol is being taught, the correct response is usually defined as touching the picture corresponding to the item on offer or 7

Choiceboard Creator

TM

touching the generic symbol (see, for example, van der Meer et al., 2012). If more than one picture and item are available and there is no indication of which item the child prefers, correct responses, valid use of pictures to make a choice, can be defined as the child subsequently selecting the item that matches the activated picture (Ganz et al., 2013; Sigafoos, Ganz, O’Reilly, Lancioni, & Schlosser, 2007). In both intervention types, a no response is often considered as an error. This may be problematic in that the child may not want the particular item on display, but has no formal means of indicating that, other than not selecting the item. As Smebye (1991) noted some time ago, the frequency of communication behavior ‘‘should vary according to the actual wish for available offers’’ (p. 87). There may also be difficulties with highly structured interventions if the participants are distractible or non-compliant, and in reported studies it appears that participants were generally compliant and completed the required number of trials. Some relevant interventions have varied the number of trials offered depending on student behavior and subsequently reported percentage correct (see, for example, Ramdoss, 2013 where the challenging behavior was elopement). Tractable participants make it easier for researchers to use clear and consistent protocols and to record consistent data such as number of correct trials. The problem is, however, that many children with severe disabilities also exhibit a range of challenging behaviors that make intervention difficult (Oliver, Petty, Ruddick, & Bacarese-Hamilton, 2012). Challenging behavior in people with disabilities can be defined as behavior that is ‘‘dangerous, destructive, harmful, disruptive, or otherwise unacceptable’’ (Sigafoos, Arthur & O’Reilly, 2003 p. ix). These behaviors may include aggression, stereotypy, elopement, and self-injury. Challenging behavior may also indicate that the student no longer wishes to engage in a particular activity (Sigafoos et al., 2003). When the aim of an intervention is to teach choosing or requesting as an expression of personal preference, setting a requirement that a student make a choice or request in order to complete a pre-set number of trials becomes problematic. Given that improved communication skills may reduce some challenging behavior, it is important to develop effective interventions for this group of students (Ganz et al., 2013; Sigafoos et al., 2013). This may mean that interventions are less structured, and that some compromises, such as flexibility around the number of trials in each session, are made in data collection. Although the basic ability to match pictures to objects and vice versa, and to select objects or pictures when given the spoken name does not necessarily indicate symbolic use of pictures (Stephenson & Linfoot, 1996), assessment of these skills may give some insight into the general development of symbols skills and the role of speech comprehension in picture recognition and use (Romski & Sevcik, 1996). Fully symbolic use of pictures develops over time. A child, for example, may be able to use one or two photos to make requests in contexts such as morning tea and lunch, but be unable to use those photos to answer questions or in other contexts. For this child,

is a product of Techno Chipmunk, http://technochipmunk.blogspot.com.

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symbolic use is emerging, but further intervention may be needed to develop full symbolic use of pictures. Where the participants in intervention studies are beginning symbol users, additional broader assessment of their picture or symbol skills may be helpful in monitoring intervention effects along with specific intervention data. For example, tabletop assessments might be used to assess the child’s ability to associate the spoken word with objects and pictures, and to associate objects and pictures (Mirenda & Dattilo, 1987; Mirenda & Locke, 1989). These tasks assess basic recognition of objects and pictures and, although their successful completion may not indicate a capacity for fully symbolic use of pictures, it does indicate that the person can demonstrate some knowledge of relationships between pictures, words, and objects. These early skills may be a precursor to full symbolic use (DeLoache, 1995; Mineo Mollica, 2003). The aim of the current study was to examine the use of the iPad app Choiceboard Creator Version 1.10 to teach choice making using photographs to a child with severe intellectual disability and autism spectrum disorder who had a range of challenging behaviors. A flexible, teacher-led intervention offering more than one item was employed. If the student did not make a response, this was not treated as an error response. The impact of the intervention on the participant’s ability to match words, objects, and pictures was also explored. The specific research questions were: Would an intervention to teach choice making with the use of the Choiceboard Creator app result in the student making valid choices? Would the intervention have an impact on the student’s ability to (a) select objects and pictures given the spoken word, (b) to select objects given the picture, and (c) to select pictures given the object?

Method Participant The participant was a 7-year-old boy, Luke (a pseudonym), who was reported by his parents to have severe intellectual disability and an autism spectrum disorder. His diagnosis was confirmed by school personnel from records held at the school. He was unable to communicate functionally using speech. He had a range of stereotypic and challenging behaviors, including hitting his chest and buttocks, banging his hands on walls and furniture, loud vocalizations, waving and watching his hands, and running around the room. He was not consistently compliant to teacher instructions and requests, and it could be very hard to engage him in activities for more than a few minutes. He needed considerable supervision to remain safe and verbal and physical assistance to complete most activities, and he was not yet independent in self-care such as toileting and hand washing. He lived at home with his parents and siblings and was in his fourth year of schooling in a segregated school that enrolled students with moderate to severe intellectual disabilities, many of whom had additional disabilities. He was a member of a class of seven students, all with intellectual disabilities, staffed by an experienced, qualified special educator and a teacher assistant.

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The focus of his individualized educational program, negotiated with his parents, was to (a) express continuation or rejection (using graphic symbols for MORE and FINISHED), (b) make choices by touching graphic symbols, (c) become more independent at toileting, and (d) respond to direct instructions to stop climbing on furniture. He was able to follow familiar one-step verbal instructions supported with gestures. He was reported by his parents and teacher to communicate through facial expression, body movements, nodding for yes and shaking head for no, vocalizing, touching or reaching for objects, touching people to get attention, and leading people to things he wanted. He was reported by his parents to use pictures and photographs at home for choice making, but school data indicated that he could only do this at school with hand-to-hand full physical assistance to touch pictures, not independently. His teacher judged that he was an intentional communicator. The researcher and his teacher agreed that he was in the early stages of developing symbolic communication, that he had limited picture skills currently used for a single function (choice making) in one context (home), and that independent use was not observed at school. Graphic symbols (photographs and colored Picture Communication Symbols [Dynavox Mayer-Johnson, 1981–2009]) were used regularly in the classroom, and he was exposed to these symbols as part of daily routines. Manual signing was also used regularly in the classroom to support speech. His teacher believed that teaching the use of the iPad for choice making was an appropriate intervention to develop early use of pictures as symbols for objects. Luke was familiar with the iPad and was reported by his parents to use it once or twice a week to watch videos and social stories. He also used it at school as a free-time activity. He was able to touch and swipe to activate apps once the teacher had opened them. However, he had never received an intervention to teach the use of a speech-generating communication device or any iPad app for communication.

General Procedures The research project was part of an initiative by the school to develop the use of iPad apps within the school, especially for communication. Approval was gained from the university Human Research Ethics committee and from the New South Wales Department of Education and Communities. Formal, informed consent was then obtained from the school principal, the class teacher, an executive teacher who could replace the class teacher if she was away, and the parents of the participant. The parents completed a short questionnaire to provide information about their child, his communication skills, and his use of iPads outside school. The assessment, baseline, and intervention procedures, and the settings and objects to be used, were developed collaboratively with school staff and the volunteer teacher. School staff selected the student as one for whom communication using graphic symbols was appropriate and part of his planned program. The teacher was provided with written guidelines for all procedures, as well as data recording sheets for recording picture and item selection and choice validity or no response trials during intervention and student responses in the pre- and

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post-assessments. The author visited at least weekly to (a) observe and make video-recordings to be used to calculate observational and procedural reliability, (b) collect data recording sheets, and (c) provide feedback on intervention implementation and progress. The intervention was implemented in three settings. The sequence of settings was determined by pragmatic considerations for the classroom teacher, with the first setting being one where the teacher could give her full attention to Luke. In the first setting, free play, the teacher interacted with the participant only, while the other students completed a group activity with the classroom assistant. Due to the student’s unpredictable behavior, the teacher offered the choices anywhere in the classroom where the student was settled, including seated at a table and sitting on the floor. In the second setting, morning circle, the whole class was seated on chairs in a semicircle facing an interactive whiteboard. The teacher ran the session with support from the teacher assistant, and all students were offered the opportunity in turn to make choices using the iPad and the objects selected for the participant student. Typically, the teacher assistant stayed close to Luke so that he remained in seat. For morning tea, the student was seated at a table with the other students who were also having morning tea, and the teacher offered the choices at the table. The intervention was designed to fit into the existing class routines, and the teacher recorded data on each trial during the intervention. The aim of the intervention was to teach independent, valid choice making using pictures. A valid choice using pictures, the dependent variable, was when the student independently activated one of the pictures in the array on the iPad and then, when the items on offer were placed within reach, took the item corresponding to the picture activated. Non-valid choices using pictures were when he activated a picture but did not take an item and when he took an item other than that corresponding to the activated picture. No response trials were when he did not touch a picture after a wait of about 10 s. The assessment sessions before and after the intervention were run with the participant student seated at a table and with the teacher seated opposite. Due to the very active and distractible nature of the student, these assessments were mostly carried out in several short sessions, with a few trials each session, while the student remained seated and attending.

Research Design The research design was a multiple baseline across three settings (free play, morning circle, and morning tea) with probes during baseline (Kennedy, 2005) and a changing criterion during the intervention. The first criterion was set as the student making at least 75% valid choices for three consecutive sessions with the first two pictures in the display. The second, third, fourth and fifth criteria were for the same standard of performance with three, four, five and six pictures respectively, with one new picture being introduced at each step. Initially, three baseline sessions, with all six pictures appropriate to the setting on display, were implemented in each setting, and then two more baseline sessions were implemented in the first setting (free play). Once the student had reached

criterion for the use of two symbols in free play, two more baseline measures were taken in morning circle and then the intervention was introduced in that setting. When the student reached the criterion with two pictures in morning circle, two more baseline measures were taken in morning tea before the intervention was introduced there. After the first step of the intervention, the interventions progressed independently in each setting and the student moved to a higher number of pictures when he reached criterion on the current number.

Intervention Materials and Settings An iPad within a black cover and using iOS6, with the app Choiceboard Creator Version 1.10 produced by Techno Chipmunk installed, was used in the study. This app displays a maximum of six pictures in a 2  3 landscape array. The number of positions in the array that display a picture can be selected and the other positions are blank, so initially two positions displayed the target photographs and the other four positions were blank. The pictures used in this project were clear colored photographs of the objects that were choice options for the student. This app has features that are not available on SGDs. Specifically, the position of the pictures in the array is varied randomly after each activation, and when a picture is activated, a recording of the name of the object is played (we used a recording of the teacher’s voice) while the selected picture enlarges to fill the screen for a few seconds. The array then resets for the next choice. The iPad was locked so that the student could not navigate away from the Choiceboard Creator app. The choice intervention was implemented in three settings: free play, morning circle, and morning tea. The teacher selected objects that the student had shown interest in interacting with and food and drink that the student preferred. The objects and the corresponding spoken word are shown in Table 1.

Table 1. Objects used in the intervention and their spoken labels. Object/activity (in order of introduction) Free play Pair of gloves representing an opportunity to be tickled iPad (not the one used as the SGD) Nail file Light that lit up when squeezed Large yellow cloth representing an opportunity to wrestle with the teacher Hand cream Morning circle Battery operated rotating light Set of electronic drums Toy pig that sang when activated Push button top Rotating light in the shape of a windmill Toy duck Morning tea Cardboard juice carton Chips Sandwich Donut Carrot Pieces of orange

Spoken word for object/activity Tickles iPad Nail file Squeezy light Wrestle Hand cream Round light Drums Pig Top Windmill Duck Juice Chips Sandwich Donut Carrot Orange

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Baseline Procedures Baseline trials were carried out with all six pictures for each setting displayed on the iPad. The teacher presented the iPad, and after getting Luke’s attention if necessary, offered a choice by showing all six items, displayed on a tray or table, to the student and asking questions such as, What do you want? or What would you like? She then waited at least 10 s for a response. A correct response was for the student to activate one picture, and then take the corresponding item, after the teacher acknowledged the picture activation by placing all items within reach. The percentage correct for each session included only trials where the student made a response, that is, trials where the student did not activate a picture were not counted because this may have occurred because he did not want any of the items offered. If the student grabbed an item before activating a picture, the teacher took the item and replaced it in the display. During baseline, the teacher offered five choice opportunities at each session.

Intervention Procedures Intervention in each setting began with two pictures, drawn from the six pictures selected for intervention and used in baseline, displayed on the iPad. The teacher chose the items to be selected in order of the student’s perceived preference. Opportunities for choices were presented in the same way as for baseline, with the items shown to the student and the teacher inviting him to make a selection using the iPad. If the student activated a picture, the teacher placed the items within reach and indicated that the student could take one. If the student did not touch a picture after a wait of at least 10 s, the teacher removed the iPad and the items and moved to the next trial. The wait period varied a little, because the student was highly distractible and the teacher used some discretion in how much longer than 10 s to wait. If the student made a valid choice, that is, if he selected the object that matched the picture, he then interacted with or consumed the object. If he selected an object that did not match the picture, the teacher removed the object and delivered the correction procedure: She said, You wanted the (says the name of picture symbol), while simultaneously physically prompting the student to activate the picture corresponding to the object selected. If the student touched a picture, but did not take an item, this was treated as an invalid choice, but no correction procedures were applied and the teacher went to the next trial. The student did not get access to an item after a prompted picture activation. The percentage correct was calculated in the same way as for baseline sessions The aim was for the teacher to implement an intervention session every day and to offer at least five choices in each session. In practice, the number of choices offered depended on student response, and on days when he appeared uninterested, very distractible, distressed, rejected the opportunity to choose by pushing the iPad away, or simply left the location where the choices were offered, the teacher used her discretion as to how many trials to present. The overall structure of the intervention was consistent, in that a choice was offered, and differing responses to valid and invalid choices were provided. There were, however, some day-to-day variations in

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that the spoken invitation of the teacher to the student to make a choice was not scripted and the teacher used a range of invitations (along with consistently offering the items and making sure the iPad was in reach). In the first intervention context, the teacher followed the child’s lead as to the actual location where the choice was offered, in order to maximize his engagement. His positioning in the morning circle context varied across and within sessions. The wait time also varied, depending on teacher judgment, but was always at least 10 s.

Assessment Procedures Before and after intervention, a set of tabletop assessments was carried out by the teacher to assess Luke’s picture skills more broadly. Laminated colored photographs of the items used in the intervention were produced that were the same photographs as those displayed on the iPad, and the objects used were the same as those in the intervention. Luke was assessed on his ability to select an object given the spoken name (comprehension of spoken names of objects), to select a picture given the spoken name (comprehension of spoken names of pictures), to select an object given a picture (comprehension of pictures), and to select a picture given an object (labeling with a picture). Each assessment session followed the same procedures. Luke was seated at a table and his teacher sat opposite. The assessment sessions, each of which comprised 18 trials, were broken into shorter times if needed owing to student behavior. The teacher first placed the target object and one distractor in front of the student, according to a pre-determined sequence. After placing the two items on the table, she then gave either (a) the cue, Give me the (says the name of the object or the picture) for assessing comprehension of the spoken word for objects and pictures; or (b) the cue, Give me this one, while holding the picture or the object as appropriate for assessments evaluating production and comprehension with pictures. The teacher then waited at least 10 s for a response. The first contact of the student’s hand with either the object or the picture was recorded as the response. If the student did not touch either object or picture, a no response was recorded. No specific feedback on whether or not a selection was correct was provided, but incidental praise for remaining seated and working well was provided at the teacher’s discretion. The same sequence of trials, with the same target for each trial, was used for each kind of assessment. Each object or picture was the target in three trials within each assessment, and use of pictures and objects as distractors was evenly distributed.

Procedural Reliability For baseline sessions, video-recordings were available for four sessions in each setting and one video from each setting was selected (18.8% of all sessions) using a random number generator for collection of procedural and observational reliability. Each video was scored using a checklist of the steps to be carried out by a research assistant who was trained on video not used in reliability checking. Procedural reliability was calculated as the percentage of steps implemented correctly in each session. Procedural reliability was 100% for

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two baseline settings (free play and morning tea) and 99% for the third (morning circle). For intervention settings, 23 video recordings were available for free play sessions and 10 (21.6% of all sessions) were randomly selected for procedural and observational reliability. For morning circle sessions, 12 videos were available and seven (22.6% of all sessions) were selected. For morning tea sessions, six videos were available and four (21.1% of all sessions) were selected. A research assistant, trained on video not selected for reliability, scored each session, using a checklist. Procedural reliability was calculated in the same way as for baseline. Overall procedural reliability for the free play setting was 96.2% (range: 69.6–100%) with the lowest scoring session due to the teacher presenting five pictures and items instead of four in one session. For both the morning circle and morning tea settings, procedural reliability was 100%. For assessment sessions, seven were recorded and five (including three from the pre-intervention assessments and two from the post-intervention assessments – 20.1% of all assessments – were used for procedural and observational reliability calculations. For procedural reliability, the research assistant watched each video and for each trial recorded which items were presented and their position (teacher’s left or right), the cue given by the teacher, and the student’s response. These were then checked against the prescribed sequence for each assessment session. Procedural reliability for the assessments was 100%.

Observational Reliability For each video recording selected as previously described, the research assistant recorded the student’s responses, whether or not a valid choice was made for baseline trials, the picture activated, and object selected for intervention trials or item selected for assessment trials. These records were then compared with the data recorded by the teacher. Observational reliability was calculated using the formula agreements divided by agreements + disagreements multiplied by 100. Observational reliability for baseline sessions was 100%. For intervention sessions in the free play setting, observational reliability overall was 98.8% (range: 84.6–100%), for the morning circle setting it was 100%, and for the morning tea sessions it was 85.7% (range: 42.9–100%). The one low scoring session was due to the teacher omitting to record four trials (which were all valid choices), so that the overall score of valid choices for this session would have remained at 100% had these trials been included in the data. For assessment sessions, the overall observational reliability was 92.1% (range: 83–100%).

absence, school events, servicing of iPads, and for one morning circle session when the student made no response to choice offers. During baseline the student made two valid choices in the free play setting, none in the morning circle setting, and three in the morning tea setting. As noted in the methods, the teacher had some discretion over the number of trials to offer in each session, with the aim of completing at least five trials in each. For the free play sessions, a mean of 5.9 trials was offered per session with a range of 1–10. In this context there was a mean of 1.2 no response trials per session with a range from 0–5. In the morning circle context, the mean number of trials was 5.5 per session (range: 5–8), with a mean of 1.7 no response trials (range: 0–4). In the morning tea setting, the mean number of trials per session was 6.8 (range: 5–12) and there was only one no response trial. The variation in the number of trials meant intervention sessions varied between 5 and 10 min in length. The student reached mastery with a three-picture display in the free play context, with a two-picture display in the morning circle context, and with a five-picture display for the morning tea context. In the free-play setting, most valid choices were for tickles; but at least one valid request was also made for the iPad, the nail file, and the squeezy light. In the morning circle condition, most valid choices were made for the round light, with valid requests for the drum and the pig. In the morning tea setting, most valid choices were for chips, with valid requests also made for donut, sandwich, and carrot. The percentage of non-overlapping data points was 80.4% for the free play setting, 80.6% for the morning circle settings, 100% for the morning tea setting, and 84.4% for the entire intervention, which is generally considered to indicate an effective intervention (Scruggs & Mastropieri, 1998). Of interest is the rapid and consistent response in the morning tea setting, where the student appeared highly motivated to choose preferred snack items, particularly donut and chips.

Pre- and Post-intervention Assessments See Table 2 for the results of the assessments (the maximum score for each task is 18 correct out of 18 trials). The number of correct trials in each assessment is provided, along with the number of trials in which there was no response. One preintervention assessment was accidentally omitted. The student performed much better after intervention than before, with chance results only occurring post-intervention. In addition, there were far fewer trials with no response after intervention (11) than before (41).

Discussion Results Intervention Results As can be seen from the graphs in Figure 1, the data were very variable, at least in part because of the variability of student behavior. The intervention extended over 4 months and was terminated due to the end of the school year. There were breaks in the data due to school holidays, student and teacher

At the end of the teacher-led intervention the student had made valid choices with 11 different pictures in three different displays to choose items in three different settings. This occurred after previous attempts to teach choice making with pictures displayed on cards had failed to produce any independent choice making and may reflect a student preference for iPad use as reported in previous studies (Achmadi et al., 2014; Couper et al., 2014; Gevarter et al., 2013). The results may also

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Figure 1. Percentage of correct (valid) choices per session.

reflect the importance of teaching picture discrimination from the beginning, as one of the first steps in learning the use of pictures as symbols (DeLoache, 1995). Features of the app that make the link between the spoken word and the picture explicit, such as enlarging the picture selected and requiring discrimination by varying picture positions for each trial, may have contributed to this result, but further research would be needed to explore the effects of these features. Although due caution should be used, given the student’s behavior and the high number of no response trials in the initial assessment, it appears that the intervention may have

contributed to an overall improvement in symbol skills. It is also apparent, however – given the lack of generalization from setting to setting as shown in the baseline measures – that this student had not yet reached a general understanding that items may be represented by pictures that resemble them, and was still developing towards fully symbolic communication (Mineo Mollica, 2003). There were no consistencies across the settings in the assessment data, although the results relating to comprehension of the spoken word are interesting. These may indicate the link between verbal comprehension and the use of graphic

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J. STEPHENSON

Table 2. Results of pre- and post-assessments (scored out of 18).

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Assessment tasks for free play items Given spoken word select object Given spoken word select picture Given picture select object Given object select picture Total correct Assessment tasks for morning circle items Given spoken word select object Given spoken word select picture Given picture select object Given object select picture Total correct Assessment task for morning tea items Given spoken word select object Given spoken word select picture Given picture select object Given object select picture Total correct Overall total correct

Pre

Post

9 (6) 3 (10) 5 (11) 6 (7) 23 (34)

9 (1) 12 (0) 5 (0) 7 (0) 33 (1)

2 2 0 1 5

(14) (15) (17) (17) (63)

6 (0) 4 (7) 11 (0) 5 (1) 26 (8)

1 (15) 3 (15) 4 (11) No data 8 (41) 36a

16 (0) 5 (7) 8 (1) 11 (3) 40 (11) 99

Note. The figures in brackets are the number of trials where there was no response. a No data for one set of trials

symbols (DeLoache, 1995; Romski & Sevcik, 1996). These authors have noted that comprehension of the spoken word for both an object and a picture may provide a link to allow a student to use a picture to represent an object. As well as providing voice output, which may support learning the link between a word and a picture as in a standard SGD (Alzrayer et al., 2014; Schlosser & Sigafoos, 2006), the app presented the spoken word as the relevant picture was enlarged, thus making the link between the word and a specific picture more salient. Again, further research with this feature is needed. The intervention was implemented by the classroom teacher in a typical classroom setting and lasted around 5–10 min in each setting. The high procedural reliability indicates it is feasible for use in a classroom. The use of iPads as SGDs is a cost effective and flexible option for many schools and families, particularly when compared to dedicated SGDs. Although the results demonstrate that the Choiceboard Creator Version 1.10 can be used for AAC intervention, because there was no comparison with other apps, there are no indications as to how particular features of the app (voice output, use of photographs of specific items, shuffling of pictures after each choice, and the enlarging of the picture activated as the name is spoken) contribute to effectiveness. Further work using alternating treatment or ABAB designs may clarify these issues. The use of probe designs may also allow better alignment between behaviors measured in baseline and intervention, and, with no requirement for continuous measures in baseline, phases may be more practical in school settings. Certainly the novel features of this app need to be explored further with respect to beginning symbol users. The current findings add to positive findings about the use of iPads and relevant apps as SGDs (Alzrayer et al., 2014; Kagohara et al., 2013; Stephenson & Limbrick, 2015), and provide information about the effectiveness of the previously un-researched Choiceboard Creator app. The rapid and consistent response in the morning tea setting indicates that for this student access to preferred snacks was extremely motivating; items and activities available during free play and morning circle did not appear to hold the same interest, and the variation in the level of motivation may

contribute to the variation in results across settings. Formal preference assessment could have been used but would have been onerous to implement, given the student’s volatile behavior, and the results may not have been helpful. The relatively rapid response in the morning tea setting highlights the impact that motivation to obtain items can have in learning to make valid choices. Light and McNaughton (2014) have noted the importance of motivation to communicate as an element of communicative competence for AAC users with complex communication needs, and the current study illustrates the impact of motivation to obtain the offered items. There are limitations of the study that should be considered when interpreting the results. In baseline, the student was presented with a six-picture display, but intervention began with a two-picture display. It may be that the student could have used a two-picture display without intervention, and that additional baseline measures in a two-picture condition would have been informative. As noted in the methods section, the dependent variable is reported as a percentage of valid or correct choices where the student independently activated a picture and then selected the corresponding object. The number of actual trials counted for each session varied, with fewer trials presented when the teacher judged the student’s behavior was disengaged, but the mean number of trials presented in each session was at least five. It could be argued that counting no response trials as errors would have provided a more accurate reflection of performance, but expression of personal preference is intrinsic to choice making and excluding no response trials provides an accurate reflection of the ability to express a preference, including a preference to not make a choice. The high number of no response trials in some sessions should also be taken into account in interpreting the assessment results. The reduced number of no response trials in the assessments completed after intervention might reflect the student’s variable behavior as well as improved symbol skills. This study contributes to the literature on teacher-led interventions to teach the use of tablet apps for AAC by describing an intervention implemented in a classroom setting with a student with challenging behavior. Although the limitations of this study must be acknowledged, the promising results suggest that the previously unresearched app with novel features may be another option for using an iPad as an SGD with students who are learning to use graphic symbols for communication. The data on picture skills more broadly suggests that, although the intervention itself had a focus on choice making, other aspects of the student’s symbol skills may have improved, particularly verbal comprehension of the names of object and pictures used in the intervention. Future research should examine the features of the Choiceboard Creator app for any further contributions to symbol learning by students with severe disabilities and should explore the broader aspects of the development of picture skills for other pragmatic functions as well as use for specific functions in specific intervention settings.

Acknowledgements Thanks to the school and the teacher who implemented the intervention and to Genevieve Godwin for completing procedural and observational reliability data.

AUGMENTATIVE AND ALTERNATIVE COMMUNICATION

Disclosure statement The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.

Funding information This research was partially funded by a consultancy payment from the school where the research was conducted to the author, as part of the NSW Department of Education and Communities Every Student Every School/Special Schools as Centres of Excellence initiative.

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