July 31, 2012 News

APP-titude: Use the Evidence to Choose a Treatment App

This evidence-based practice model provides strategies for selecting an app.

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Speech-language pathologists face increasing demands for competency with apps and other technologies in their practice. It can be a daunting task to select an app for your specific client and treatment context.

Reimbursement regulations from Medicaid and Medicare (Rao, 2011) and requirements outlined by the Individuals With Disabilities Education Act (IDEA, 2004) emphasize the importance of using the evidence to select tools and supplementary aids for intervention. App developers' descriptions and customers' reviews, however, may lack discussions of evidence and contain inherent biases. SLPs who use only this information may be relying solely on opinions and advertisements to make decisions.

One way to select an app involves using five steps rooted in evidence-based practice (EBP), illustrated by a case study of an SLP's search for an app targeting prepositions in preschoolers with language delays. She used the EBP strategies discussed by Dollaghan (2004) to guide her process.

Step 1: Frame your clinical question using PICO (Population, Intervention, Comparison, and Outcome).
The SLP started her question as, "What is a good app for teaching prepositions?" (Schaber & Wakefield, 2011). Using PICO, the SLP rephrased the question to, "Will preschoolers with delayed language skills produce prepositions in a developmental order similar to typically developing preschoolers during elicitation tasks involving one-word structured modeling with pictures?" This SLP needed an app that modeled prepositions in structured tasks with the prepositions presented in developmental order.

Step 2: Find the evidence.
The SLP set a time limit of 30 minutes for her Internet search, while using high-yield databases. The SLP searched the ASHA Compendium and discovered evidence that early intervention was beneficial compared to no intervention (ASHA, 2011). Next, she reviewed the minimalist model theory that indicated core word development (including prepositions) could be accomplished through structured modeling by adults (Chomsky, 1998). The ERIC database provided an extensive review study by Durkin (1980) that described a specific developmental order of prepositions in typically developing children.

Step 3: Assess the evidence.
The SLP reviewed her findings to determine usefulness, quality, and the level of evidence from high to low (Robey, 2004). The most useful information for the SLP was the justification of a modeling format for elicitation (Chomsky, 1998) and the normative data review research by Durkin (1980).

Step 4: Search the app store and consult the evidence.
The SLP searched the speech language therapy section of the apps store for her device. She found two apps for English-speaking preschoolers targeting prepositions, "App M" and "App R." Neither included much information on an evidence base.

  • App M included 23 prepositions; App R had 20.
  • The prepositions were not listed for App M in its description, but were listed for App R.
  • The prepositions listed for App R were presented in alphabetical order, not developmental order.
  • Neither app described whether the app was based on a modeling format or how the preposition stimuli were chosen. The SLP realized she would have to purchase the app or contact the developers to find out that information.
  • The cost of App M was $2.99 and the cost of App R was $7.99. Considering that the average cost of an app is $3.10, App R seemed expensive to the SLP (Rosales & Linn, 2011).
  • App M was based on a modeling methodology, whereas App R was a receptive task.

The clinician chose App M because this aligned with her particular PICO question.

Step 5: Make a clinical decision and integrate the different types of evidence to determine your choices.
App M lacked any description of a research base in its help screen. The SLP discovered the prepositions were not presented in developmental order on App M—instead, the later-occurring prepositions were presented first and some of the early-occurring prepositions were presented last. Also, she noticed two of the middle-occurring prepositions were omitted. Fortunately, the user can control which prepositions were presented by selecting on/off for each word, and the SLP could set up the app to present the early-occurring prepositions first. As this SLP entered her particular treatment situation for the day, she was prepared to use App M in an informed and purposeful way. Furthermore, she now had a beginning foundation of evidence upon which to build and make decisions related to continued use of this app.

The clinician then gathered data on her preschool students' reactions and about the app to determine if it was of value to them. With this information, she could triangulate the evidence of the research base, client's values, and clinician's experiences. Finally, to engage in the continuous recursive nature of EBP, she disseminated her findings to other SLPs by writing a review of the app from this framework.

Lara Wakefield, Lara Wakefield, PhD, CCC-SLP, is in private practice at Wakefield Consultation Services, LLC, in Columbia, Missouri, and studies the decision-making processes of SLPs selecting apps as treatment tools. Contact her at wakefieldconsultationservices@gmail.com.

Theresa Schaber, Theresa Schaber, MS, CCC-SLP, is a clinical fellowship supervisor at a skilled nursing facility in Houston, Texas, and studies evidence-based apps for patients in adult rehab settings. Contact her at tjschaber@me.com.

cite as: Wakefield, L.  & Schaber, T. (2012, July 31). APP-titude: Use the Evidence to Choose a Treatment App : This evidence-based practice model provides strategies for selecting an app.. The ASHA Leader.


American Speech-Language Hearing Association. (2011). Compendium of EBP Guidelines and Systematic Reviews. Available at www.asha.org/members/ebp/compendium.

Chomsky, N. (1998). The minimalist program. Journal of Linguistics, 34, 213–226. Available at journals.cambridge.org/action/displayAbstract;jsessionid=98B7F78D9FF3DF79B2287697966616B8.tomcat1?fromPage=online&aid=16973.

Dollaghan, C. (2004). Evidence-based practice: Myths and realities. The ASHA Leader, April 13. Available at www.asha.org/Publications/leader/2004/040413/f040413a1.htm.

Durkin, K. (1980). The production of locative prepositions in young school children. Educational Studies, 6(1), March 1980. Available at www.tandfonline.com/doi/abs/10.1080/0305569800060102#preview.

Indviduals with Disabilities in Education Act (IDEA) Reauthorization of 2004. Available at http://idea.ed.gov/explore/view/p/%2Croot%2Cdynamic%2CTopicalBrief%2C3%2C.

Robey, R. (2004). Levels of evidence. The ASHA Leader. Available at www.asha.org/Publications/leader/2004/040413/f040413a2.htm.

Rosales, L., & Linn, R. (2011). Evolution of the Smartphone apps over the years
Infographic. AgBeat. Available at http://agentgenius.com/real-estate-technology-new-media/the-evolution-of-smartphone-apps-over-the-years-infographic.

Schaber, T., & Wakefield, L. (2011, May). Field Notes, #5: Qualitative data summary from: How do SLPs select apps for therapy? Pilot survey data.


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