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Too Much of a Good Thing: Technology, Apps, and Auditory Verbal Therapy

July 11th, 2011 by | Tags: , , , | 9 Comments »

I love technology.  I love the ability it gives me to communicate with people around the world about the miracle of cochlear implants and listening and spoken language.  I love that, though YouTube, eBooks, Facebook, twitter, flickr, and webinars, Rachel and I are able to reach out to people with hearing loss and their parents to share information, advice, ideas, and support.  When used correctly, technology can be an amazing tool!


So, what’s the downside?  As much as I love technology, I am dismayed by the growth in popularity of technological applications for speech-language pathology, more specifically, the proliferation of “apps.”  Not a day goes by that I’m not met with a request from a parent for recommendations for computer software, electronic toys, or apps to increase their child’s listening and speaking skills.  But parents are not the only ones to blame.  Perhaps more disappointingly, I see the same blind embrace of any and all technology in my fellow Speech-Language Pathologists.  In one SLP listserv to which I belong, approximately 90% of the posts are about smartphones, tablets, and various applications for those platforms to be used in therapy.  Ninety percent — and that’s a conservative estimate — of these professionals’ discussion is about technological games.  Not research, not evidence-based practice, not case studies.  Apps.  Gizmos.  Ways short circuit the process of human interaction that is integral to communication.


I am opposed to this trend for several reasons:

  • We’re not teaching children to talk to a computer.  We’re teaching them to talk to people.  Practice for the outcome you want.
  • There is no research behind the vast majority of these apps.  Just because it looks good does not mean that there are peer reviewed studies supporting its efficacy.  “Angry Birds” is a fun game, too, and it has just as much research supporting it as the majority of these apps.
  • There is a large possibility for “wrong practice” with these apps.  Without an adult listener monitoring the child’s productions, he or she could play away all day long hearing or pronouncing something incorrectly without any evaluative feedback.
  • The American Academy of Pediatrics recommends NO television (and, by extension, electronic media) for children under two, and limited exposure thereafter.  This position statement comes with a slew of peer reviewed journals supporting their rationale.
  • While some parents may use these apps as part of a comprehensive therapy program, many parents (and therapists) use them to the exclusion of tried and true therapy methods.  Promoting these research-less apps encourages these people to be negligent in their practice, and normalizes “plug in therapy” as an appropriate intervention.
  • One of the principles of AVT is that therapy is diagnostic.  That means, in the session, the therapist is constantly recalibrating the activities based on the child’s responses, and teaching the parent to do the same — to scale up or scale down the level of difficulty, to acoustically highlight this or de-emphasize that, all based on what the child is doing and saying in real time.  Apps cannot do that — again, there’s the possibility for lots of wrong practice.
  • One of my best tools in therapy is my ear (okay, actually, I stole that from the venerable Jean Moog, who always says that the teacher’s best tool is her own ears to listen to what the child has to say).  When a child gets something wrong, I ask, “What did you hear?” to gain info about why they made the mistake they did.  Though error analysis, I gain a better picture of the mistake.  An electronic device knows only “right” and “wrong.”  So, if the child’s first guess is wrong, he can keep tapping buttons until he finally gets it right.  It’s just chance.  Do we know why he made the mistake in the first place?  No.  So how can we ever get at the problem that led the mistake to occur?
  • On a professional level, I feel that the proliferation of the use of apps in therapy encourages shoddy practice.  As a parent, or school administrator, or insurance company, I would be hesitant to foot the bill for app-based therapy that I could be providing, with the help of a smartphone, without the “supervision” of an SLP.  Again, I have seen no peer-reviewed research that apps+SLP is any different that the child playing at the apps alone.  In that case, for what reason is the professional being compensated?  I my opinion, that professional is not doing his/her job.


I am not a complete Luddite.  In the past, I’ve posted about hearing-related apps that are fun ways to measure sound and learn more about the process of hearing, but these apps are neither diagnostic nor therapeutic, and should not be used in place of professional services.  I also use my smartphone in therapy as a source of music, background noise, or to look up a picture or concept if the child is learning new vocabulary.  The tide of technology is not one that is turning back anytime soon.  If peer-reviewed research emerges showing that apps are better than person-to-person therapy, I will gladly eat my words.  Until then, however, I urge everyone to proceed with extreme caution and not get swept up in a trend that has little base in evidence-based practice.



Written by

Elizabeth Rosenzweig MS CCC-SLP LSLS Cert. AVT is a Listening and Spoken Language Specialist Certified Auditory Verbal Therapist. She provides auditory verbal therapy, aural rehabilitation, IEP advocacy, consultation, and LSLS mentoring for clients around the world via teletherapy. You can learn more about Elizabeth's services on her Website or Facebook.


July 11, 2011 at 11:25 am

I have just read your report and have to take the time to say this was very well done and will be sharing this across my professional network :)
Keep up the good work also x


July 11, 2011 at 2:32 pm

Wow– I had no idea that people were using apps for therapy! I guess I shouldn’t be surprised. Any app or game or TV has always, in my mind, been entertainment for when the real therapy/discussions/fun is not able to happen (such as a car ride on the way TO therapy)! :-P

July 11, 2011 at 10:56 pm

I do think we need to tread with caution here. Even adults it can be overwhelming and not really a great speech learning tool.


August 8, 2011 at 2:47 am

I think you have some great comments relating to how this new and upcomming technology should be used with caution, especially due to factors relating to EBT. I however, feel that this technology can create many new avenues for therapists and clients…especially in the way of AAC and use with children with Autism Spectrum Disorders. More EBT needs to be done, but don’t rule these new tools out based on old ways or technology bias! It is my belief that this will be the wave of the future in therapy services.


August 8, 2011 at 2:55 am

Thank you for the comment, Jason! I agree that I will be happy to eat my words if some good, peer-reviewed research comes out showing the effectiveness of apps and other new technology in therapy. I have yet to see any, just baseless claims from app producers. As for AAC use, I think iPads and other tools can be effective as communication devices — they are often less expensive and easier to modify, too. In that case, though, the device isn’t taking the place of therapy, it’s just the same (if not better) than commercial products from companies that do “just” AAC. In terms of treatment for ASD, I’ll have to disagree with you. If fundamental issues for children with ASD are problems with socialization and pragmatic language, talking/communicating/interacting with an electronic device is the opposite of what we would want! Though it may be more motivating for the child, does it get at the root problem of his/her communication disorder? I would argue no. Either way, thanks for adding to the discussion!


November 1, 2011 at 4:34 am

Are you opposed to the idea of a “therapeutic app” that does not replace therapy, but instead can provide fun auditory stimulation in between sessions? I am thinking of developing an application for children with cochlear implants as part of a college project, and I would be interested in talking more about your thoughts on this. Also, I would appreciate seeing any links to CI therapy apps that you have seen out there, as I have been having trouble finding any. Thank you!

February 27, 2012 at 3:55 pm

I think you have some great points. However, I’m strongly of the belief that a good therapist can use materials that encompass a variety of media in a responsible manner in order to keep the client engaged and learning. The EBT is the principle, not the materials used. The fundamental therapeutic principle or presence of diagnostic therapy doesn’t change just because a different media is used…it’s how the therapist/family chooses to use it. For example photo cards are fundamentally no different than cards with illustrations which are no different than real objects or those same photos shown on an electronic device like an iPad. A therapist can just as easily provide lousy therapy with “traditional” media such as worksheets, mainstream games or computer software (and unfortunately many do!).

I think this all comes back to emphasize that we as individuals need to make sure that regardless of the materials we use, we’re staying true to the interactive nature of our therapy and not just putting something in front of a client to work on independently…be it worksheets, a computer program, or an app.

(Full disclosure, I just released a Ling Sound app. I actually saw this post prior to starting development. In the instructions for use of my app I reiterate that it should be used as a tool in collaboration with a CI professional)


March 1, 2012 at 4:35 am

Thank you for your comment, Mellisa, and for disclosing your financial interest in promoting apps. I agree that a variety of therapy materials can be used to provide poor quality services (which is why you won’t see me promoting worksheets and other “cookbook” therapy on this site, either), but I do disagree with your assertion that, “photo cards are fundamentally no different than cards with illustrations which are no different than real objects or those same photos shown on an electronic device like an iPad.” This statement is actually quite contrary to published research on the subject.

Science shows us that the ways in which children process these types of images are actually fundamentally VERY different. Children’s ability to interpret and use images is highly dependent on their iconicity and level of representativeness (see Simcock and DeLoache, 2006 in Developmental Psychology for one example, among many, of this principle). While iconicity of images is helpful for children, no visual representation is ever as effective as real life objects and real life experiences. Our children deserve real experiences and real interactions with adults who are truly present.

March 25, 2012 at 7:14 pm

Thanks for responding Elizabeth, I love that this is can be a productive forum for professional discussions.

I need to clarify that I absolutely agree with the research and your response that real life experiences and interactions are critical and I also believe that they are essential for the introduction of new concepts and skills. My philosophy (and my intent with my earlier statement about modality) is that these materials can be a terrific supplement or another mode for carryover, NEVER a replacement and NOT as the introductory presentation of a new skill or concept. When I said that those modalities are fundamentally the same, I was referring to children who have already acquired the concept or older children, not our little guys who are brand new to sound/language.

Although I do feel that there is a place for incorporating technology into our therapy, I absolutely am not suggesting that it is a “one stop solution” nor that it should be our primary focus in any therapy session.