Our chat tonight, March 4, 2002, is being hosted by Terri B. Nichols,
Clinical Specialist and Speech-Language Pathologist.  Terri obtained her M.S. in
Speech/Language Pathology from the University of Washington. She
received her B.S. in Communication Disorders from Northern Illinois
University. Terri is currently a Speech/Language Pathologist in Private Practice.
Terri started Bungalow Software in 1996 with her husband, a computer programmer,
to provide a way for her patients to continue therapy practice at home after
insurance coverage for intervention expired. She will chat tonight about using
computer software to assist in speech-language recovery.

<Adrienne> We are chatting with Terri Nichols about using computer software to assist
          in speech-language recovery.
<Terri> Sounds good.... so, any questions to start with?
<Erika> Terri, remind us what population your software is focused to?
<Terri> Our software is primarily geared towards recoverees from stroke and head injury.
<Terri> Aphasia and cognition, plus a little bit of motor speech.
<Terri> Adrienne, have you had any experience using software with any clients?
<Adrienne> I am using the Visi-Pitch with a client I have now.
<shanna> Is the software just called bungalow, or is there a more specific name?
<Terri> Actually, the company is Bungalow Software - we have a lot of different programs.
<Sarah> Well - here's a basic question... how does software treatment benefit the patient and
          clinician (as opposed to traditional treatment)?
<Terri> Sarah - There are several benefits - the prime one being that the client can do a lot
          of drill practice independently, to supplement therapy.
<shanna> So does each program target specific areas?
<Terri> Yes - there are programs that focus on reading comprehension, naming, verbal and written,
          articulation, etc.
<Terri> With limited insurance benefits for therapy, I think it's important to focus in 
          sessions on really functional communication and caregiver training.
<shanna> Are the programs cost effective for patients?
<Terri> The programs are very cost effective, especially if insurance benefits have run out.
          The cost of one program is about the cost of one hour of private therapy, and gives
          them hundreds of hours of treatment.
<Adrienne> wow!
<Adrienne> is the feedback specific?
<Terri> The feedback is designed to help cue the patient along. For example, if the user
          misspells a word in written naming, the program can either point out where the errors
          are, or give them a multiple choice list.
<Adrienne> does the clinician have control of the cueing levels, etc?
<Terri> In the pro version, the clinician controls which cues are presented in which order.
<Adrienne> gotcha
<Erika> Do you think your software could be used with clients in rural places that maybe can't
          get to an SLP regularly?
<Terri>Also, I think it's excellent for patients in rural areas. We have a lot of customers
          in foreign coutries, where it's tough to get therapy in English.
<Erika> oh wow
<Julie> Many stroke victims are "older"... are there problems convincing them to try the computer?
          Do they show preferences for SLP-direct therapy, or computer therapy?
<Terri> We've actually found that older folks are really thrilled with using technology - it's
          such a boost to their self-esteem, when they can actually do something "high-tech" after a
          stroke, when some of their friends don't have any computer experience.
<Adrienne> follow-up to Julie's question- is there a "best" way to present software use to a
          client to ensure use?
<Terri> In terms of the best way to present the software, we usually recommend starting out as
          if it is a paper task, having the client point to items on the computer monitor to answer.
<Adrienne> Perhaps a case example would help us see how software can work- say, with a Wernicke
          Aphasia patient?
<Terri> All our programs are designed to run from the keyboard or mouse, so if they're novices,
          all they need to be able to use is the space bar and enter key.
<Adrienne> The paper-like approach makes sense, thanks.
<Terri> For a Wernicke's patient, I might start with something like Sights n' Sounds. It records
          the person naming a picture, then plays back their recorded voice, plus a model of the
          correct answer.
<Erika> that's cool!
<Terri> It's great for building in error recognition. I might also work on written naming with
          Aphasia Tutor 1, so they could use writing as a backup.
<Julie> Does the software have any built-in ability to automatically email progress reports to you?
<Terri> It doesn't automatically e-mail reports, but it saves all the progress reports in files
          which can be printed.
<Adrienne> good question Julie- it would really help to have that data from home-use

<Erika> So what's needed then to run your software in addition to a keyboard and mouse?
<Terri> For a few of the programs, you need a sound card, speakers, and microphone - other than
          that, it can run on a pretty basic PC - even Windows.
<Adrienne> how does the computer assess writing?
<Terri> As far as writing, so far we're just at the single word written naming level. For discourse,
          I actually use plain old Microsoft Word, with the features turned on to point out grammar
          and spelling errors.
<Adrienne> It's actually not a bad idea since often handwriting with a non-dominant hand is not so
          pretty (or legible).
<Sarah> Since the computer is supposed to complement traditional therapy, what proportion of the
          therapy is spent working with the computer?
<Terri> Proportion of time spent in therapy and on the computer really varies by patient. I've had
          patients who get 2 hours of therapy per week, and work 2 hours a day on the computer at home...
          it depends on motivation.
<Terri> I've also had a lot of folks get hooked on the computer for their recovery, and then really
          get into e-mail.
<Terri> We've been collaborating with a colleague at the Univ. of Oregon who's been looking at creating
          a simplified e-mail interface for patients with head injury.
<Adrienne> That would be great!
<Julie> Re time-in-therapy vs. time-on-computer... what do you hope for? Is 2 hours/day a real keener?
<Terri> Two hours a day is actually pretty amazing - if a patient can spend an hour a day on non-therapy
          days, that's pretty good. It's not at all that I think computer time vs. direct therapy time
          should be a ratio, but it's pretty rare to get more than 2 visits per day on an outpatient basis
          and patients definitely do better with daily practice.
<Adrienne> Terri, can you differentiate between software for therapy and AAC tools?
<Terri> Regarding therapy vs. AAC the biggest distinction is that therapeutic software doesn't create unique
          messages from the user - it elicits specific vocabulary to train. Although Lingraphicare does mix
          the two a bit, from what I understand of their program.
<Erika> Do you offer samples for download?
<Terri> Yes - all our programs are downloadable - actually, what you download is a fully functioning program,
          that is just limited as to how many times you can use it without purchasing.
<Adrienne> Does Medicare or insurance fund therapy software?
<Terri> We've had a couple of insurance companies pay for it, on a case by case basis.
<Julie> Can you use your software to assess the disorder? And plan treatment objectives?
<Terri> There are no norms for any of our programs at this point, but it can certainly give you some
          baseline data.
<Terri> I still use the good ol' Boston or MTDD.
<Adrienne> You can use the Visi-Pitch for Voice assessments.
<Adrienne> It's nice because voice can be so subjective!
<Terri> That's true - does Visi-Pitch generate a report, too?
<Adrienne> I'm not sure, in the past I have just copied the relevant data and put it into my report.
<Terri> I used to use Dr. Speech - which generates a report, but it was about 6 pages long - no MD would
          ever read it. 
<Terri> It did have some before and after graphs and things.
<Erika> too much information!
<Adrienne> It's hard to pick out what matters, but insurance companies like to see numbers- even if they
          don't mean much
<Sarah> I guess software treatment is being used more and more nowadays both in private practice and in
          hospitals, etc. Do you have any idea how widely it is used and how effective it is?
          (ie- any stats?)
<Terri> There have been a couple of efficacy studies, specifically for aphasia and head injury.
          If you go to the Bungalow website (www.bungalowsoftware.com) , there's a link to all the
          efficacy studies.
<Erika> How helpful!
<Terri> The studies are pretty impressive, actually - and they show that working on a specific
          language skill carries over to other areas of language, as well.
<Erika> What do you think about developing software for child therapy needs?
<Terri> There's actually a lot of excellent child language software - Laureate has some excellent stuff.
<Erika> oh really?!
<Terri> There's also a great company...I think it used to be called Merit, but I'm not sure if that's changed,
          that has excellent stuff for school-aged kids, and guided discourse.
<Julie> That brings up a good question... any bilingual versions of the software?
<Terri> We have one or two programs being translated into Spanish.... I know that Parrot has some programs
          in Spanish and French.
<Adrienne> Would that work if the clinician didn't know the other language?
<Terri> I'm actually not sure if all the instructions are in the other language....that's what we're doing
          in our translations.
<Terri> I guess it depends on how straightforward the task is....luckily, the computer is doing the assessment
          of whether or not the answer is correct, I suppose.
<Julie> Bilingualism would be an interesting problem for software to solve. I was listening to a specialist talk
          on this subject not long ago; one of the most interesting facets of her treatment programs was figuring out
          "how" the languages were getting crossed.
<Terri> It's also tough, because there are so many cultural differences. I've done a lot of assessments and
          treatments through an interpreter, which was quite an education!
<Julie> I guess that's the tricky part! -)
<Adrienne> Has anyone here used any software in therapy?
<Erika> I have, but it was for preschoolers.
<Terri> What did you use with the preschoolers?
<Erika> Preschool jumpstart
<Erika> nothing like what Terri develops.
<Julie> How did that go? Did they have fun?
<Erika> Yes, the child had autism. He liked making the shapes move and talk.
<Adrienne> What is jumpstart like? How is it different than Bungalow's programs ?
<Erika> Jumpstart is for any preschooler...you can buy it at any store that has software for kids.
<Erika> It has matching, story creating, coloring, musical instruments...stuff like that.
<Erika> Nothing that really encourages speech production per se.
<Terri> Back in my early days as a therapist, I worked at Children's Hospital in Seattle. We did a lot with kids
          with CP, using adapted computers with single switches to use basic preschool software.
<Erika> But I was able to get my client to interact.
<Terri> It's really nice to give a kid control over something.
<Adrienne> Terri- how do you differentiate between things like Jumpstart and boardmaker (anyone not know what
          boardmaker is?) and your therapy software?
<Terri> As far as Jumpstart or general preschool concept software, I guess I'd say that the difference is that we
          are very targeted towards specific disorders, rather than normal language acquisition.
<Terri> We're different than Boardmaker in that we are for the client to interact with directly, rather than being
          a tool for the therapist to use in creating treatment materials.
<Adrienne> That is a difference!
<Julie> How do you go about deciding how to enhance the software? How do you find ideas, and how do you prioritize them?
<Terri> Good question - mostly from feedback from customers (or potential customers). I don't think I ever answered the
          question about the variety of difficulty levels - we start out at the most basic levels - letter matching,
          word copying, multiple choice...
<Terri> Based on feedback from clients, we've developed much higher level word retrieval tasks.
<Sarah> Is there any difference in the results (generic vs designer)- after the clinician has adapted the generic software?
<Adrienne> Good question Sarah. Maybe generic would be more cost-effective for a clinician with many clients?
<Terri >I'm not sure if I understand what you mean by "generic" vs. "designer" - do you mean like retail stuff you can get
          at Office Depot, vs. therapy software?
<Sarah> yes
<Sarah> I guess commercially available software would mostly be targeted to kids anyways.
<Terri> I think there are a lot of broad kids' programs that are excellent, without much modification.
<Erika> Can you pick and choose different components for the client to work on?
<Terri> Erika - Yes - the clinician chooses the target area, as well as the difficulty level.
<Terri> For the aphasic adult, however, most software where the content is basic enough is really insultingly childish.
<Terri> Also, a lot of broad-appeal software actually requires pretty agile mouse use, which many stroke recoverees can't master.
<Adrienne> oooh, that sounds like a big obstacle- what type of content do you use to make it more age-appropriate/ functional?
<Terri> We definitely focus on very functional vocabulary - foods, household objects, etc., with adult-appropriate feedback.
<Terri> In Windows 95 and higher, there are actually a lot of settings you can use to adapt the mouse - under "accessibility options".
<Adrienne> Is there any adaptive equipment for a mouse in terms of sensitivity? 
<Terri> You can slow down the click rate, switch the right and left buttons, make the mouse pointer larger, and make the cursor leave
          trails on the screen.
<Adrienne> Terri, Trackballs are also a good option for some folks.
<Erika> I have a trackball and I love it )
<Terri> There's even something called "mousekeys" in Windows, which allows you to use the numeric keypad for mouse functions.
<Terri> It's like the arrows radiate out from the number 5 on the keypad, and you use the 5 to click and double click.
<Julie> Terri, who are most of your customers? Home users? Private practice? Institutional types (e.g. hospitals, nursing homes)?
<Terri> We get a little of everything - probably in sheer numbers, most of our clients are home users, but that's slowly changing.
          We always try to get home users to show our stuff to their therapist, to have them guide them on what's appropriate.
<Adrienne> Our time is almost out, any final questions about our topic tonight- software for speech therapy?
<Julie> Sure. Software is great for drill and practice. Is there anything that you've found that it just really isn't any good for,
          at all?
<Terri >Yes - pragmatics!
<Adrienne> lol
<Erika> haha
<Terri> Also, seriously, it doesn't help folks develop compensatory strategies - but I'm afraid a lot of therapists don't spend
          enough time on that!
<Terri> Software is also really limited in remediating verbal and written discourse.
<Adrienne> Maybe the software programs would allow more time during therapy sessions for strategies and pragmatics.
<Terri> That's definitely how I use it - again, make use of those sessions that really uses your skill!
<Adrienne> Well Terri- it sounds like there is an appropriate and effective place for software with all types of speech therapy cases.
<Adrienne> Thank you so much for chatting with us- very informative tonight!
<Erika> I love this subject!
<Terri> You're very welcome - thanks for inviting me!
<Julie> One last question...Have you enjoyed the time you've spent developing developing the software? Would you do it again?
<Terri> Absolutely
<Terri >I have to say, in all honesty, I've really seen it make a difference for people.
<Julie> Thanks for all of the info. I agree with Erika. It is a really, really great subject.
<Adrienne> Thanks, Terri, for sharing your knowledge and expertise with us!
<Adrienne> goodnight everyone!
<Terri >Good luck with all your studies!
<Terri >Goodnight