Abstract
Students diagnosed with specific learning disabilities, autism, or emotional disturbance may also receive speech-language services as part of their individual education program. This article focuses on the use of telepractice for providing speech-language services in schools. The benefits of telepractice are described, including the accessibility, efficiency, and preference of telepractice in delivering effective speech-language services. In addition, the implementation of telepractice services is outlined, strategies for troubleshooting are described, and two implementation checklists are provided.
Students with specific learning disabilities, autism, or emotional disturbance and a speech-language impairment may receive speech-language services as a related service. These services are delivered by speech-language pathologists (SLPs) who identify, evaluate, diagnose, and treat communication disorders. Students who qualify for speech-language services may exhibit deficits in articulation (i.e., producing speech sounds), language (i.e., understanding and expressing ideas with words), fluency (i.e., flow of speech sounds), and voice (i.e., pitch, volume, and tone of vocal utterances). In the school setting, traditional service delivery models provide most students with weekly therapy sessions in a small group setting, but other service models include push-in services in the general education classroom or consultative services (American Speech-Language-Hearing Association [ASHA], n.d.-b). To improve service delivery, some students are beginning to receive school-based speech-language services virtually through telepractice. This article explores the use of telepractice for providing speech-language services in schools. To accomplish this goal, first, an introduction to telepractice is provided. Then, the benefits of telepractice—including the accessibility, efficiency, and preference of telepractice in delivering effective speech-language services—are described. Next, the implementation of telepractice services and strategies for troubleshooting are provided.
Telepractice is defined by ASHA as “the application of telecommunications technology to the delivery of speech-language pathology and audiology services at a distance by linking clinician to client or clinician to clinician for assessment, intervention, and/or consultation” (ASHA, n.d.-d, para. 1). Improvements in digital technology, as well as improved infrastructure for digital communication over the past 10 to 15 years, have made the expansion of remotely addressing client needs more accessible and efficient (Ben-Aharon, 2019; Cason & Cohn, 2014). Changes in health care policies and the need to better serve individuals in more rural areas have further fueled the rise of this type of expanded service delivery (Houston, 2012). As a result, telepractice is growing in popularity as a convenient, efficient, and effective method for obtaining speech-language services.
Telepractice Effectiveness and Benefits
The effectiveness of telepractice for speech-language services is well documented, although more studies have examined the online service delivery model with adults than children, and few studies have examined telepractice in school settings (Ben-Aharon, 2019). Studies with children indicate that articulation, language, and fluency services can be delivered to children via telepractice as effectively as traditional therapy (McGill et al., 2019; Wales et al., 2017). School-based language screenings are as effective with telepractice as screenings delivered face-to-face (Raman et al., 2019). In addition, assessment, communication therapy, behavior, and anxiety outcomes for children with autism via telepractice are equivalent to traditional in-person services (Sutherland et al., 2018).
Accessibility of Services
Telepractice offers both the continuation of uninterrupted services to current clients and the extension of far greater access to services that might otherwise be limited or non-existent to clients (Crutchley & Campbell, 2010). Tele-practice was integral in providing speech-language services designated in students’ Individualized Education Programs (IEPs) during long-term school closures due to the COVID-19 pandemic and have also been used for short-term school closures due to weather (Cason & Cohn, 2014; Tohidast et al., 2020). By using telepractice to maintain implementation of services during school closures, school districts may avoid the need to provide compensatory services (U.S. Department of Education, 2020). Districts may also struggle to provide speech-language services mandated in a student’s IEP due to shortages of SLPs nationwide (Cross, 2017; Squires, 2013). Hence, telepractice avoids delays in services when an SLP is not available in the local community by contracting with providers in other areas (Ben-Aharon, 2019; Grogan-Johnson et al., 2011). In addition, school districts use telepractice to provide speech-language services to students who are not receiving educational services in the school building, such as students receiving their instruction at home (Ben-Aharon, 2019), students placed in alternative school settings (e.g., juvenile detention; Cason & Cohn, 2014), or private and home-schooled students who qualify for speech-language services with a designated portion of special education funds (McCrea, 2013).
Telepractice extends to collaboration and specialized support for both the SLP and the student to other SLPs or service providers. Telepractice for collaboration may include providing caregiver training of new therapy techniques (e.g., use of augmentative and alternative communication devices; Hall et al., 2014) or for instructional coaching when students are in the home setting during school closures (Reimers & Schleicher, 2020). In addition, telepractice allows the needs of a student to be matched with the expertise of a therapist (Ben-Aharon, 2019). For example, a bilingual SLP can provide therapy to an English-language learner diagnosed with a learning disability and speech-language impairment in another state (i.e., regulations follow).
Telepractice Is Efficient
Telepractice allows SLPs to provide interventions to students in multiple locations efficiently. The online platform eliminates the need for travel, thereby reducing time, costs, and physical energy required when SLPs provide face-to-face services in multiple locations (Fairweather et al., 2016; Towey, 2012b). For example, an SLP in a rural area can avoid wasted time and expensive mileage reimbursements by providing speech-language services to four students receiving specialized behavior supports in an out-of-district placement an hour away via telepractice. Also, delays in services can be avoided, such as when technical support is required by a specialist. For example, a student with autism in Iowa who uses an accessible and alternative communication device may receive immediate programming support from an assistive technology specialist in Connecticut for an issue that could not be resolved by the student’s local school team.
Students are likely able to begin receiving telepractice using hardware currently available in the school district. Using a basic computer connected to the internet, web camera, and headset, many students can easily login and begin receiving services (Grogan-Johnson et al., 2011). Telepractice is available almost anywhere there is an adequate internet connection but is best provided in a quiet room to avoid distractions and ensure privacy. In most cases, staffing only requires an e-helper (e.g., paraprofessional, caregiver) to assist the student logging in for the therapy session, to handle any technology challenges, and to provide speech-language intervention support, when needed (Grogan-Johnson et al., 2010).
User Satisfaction
Therapists and students, as well as parents, teachers, and administrators, report high levels of participant satisfaction with the telepractice format (Crutchley & Campbell, 2010). Features of telepractice even make it a preferred delivery model for some users. The on-screen interaction between the SLP and student may increase treatment engagement for inattentive students or buy-in for computer-savvy students reluctant to attend speech-language therapy sessions (Ben-Aharon, 2019; Hines et al., 2019). Student privacy is increased as students are observed working on a computer rather than sitting with the SLP (Lincoln et al., 2014). Speech-language pathologists describe greater parental buy-in and engagement as parents can discreetly observe the therapy session remotely or access online session notes commonly available in telepractice platforms (Akamoglu et al., 2018). Telepractice can even promote generalization as services are provided in the student’s environment rather than in an unfamiliar therapy room (Cason & Cohn, 2014).
Telepractice Implementation
When considering telepractice as a service delivery model for a school district, a variety of factors need to be considered or addressed. In this section, considerations as districts prepare to provide services, begin sessions, and implement ongoing sessions are provided.
Initial Preparation
Administrative approval
Administrative approval and decisions regarding budgets, equipment, personnel allocation, and training factors will need to be reached before implementing the alternative service delivery model (Tucker, 2012). For example, school-based speech-language therapy sessions are most frequently delivered in small groups while telepractice is often conducted individually with the student (Crutchley & Campbell, 2010). Methods for providing inclusive supports via telepractice may have to be considered. Administrators may face challenges with finding an appropriate setting (i.e., room with good lighting in a location free from ambient noise and visual distractions; Ben-Aharon, 2019) in schools that are experiencing overcrowded conditions.
Regulations
When implementing online therapy, including group sessions and consultations, the client’s confidentiality and privacy of personal information and health records will need to be protected as outlined in the ASHA Code of Ethics (ASHA, 2016). School-based practitioners will need to comply with the Family Educational Rights and Privacy Act (FERPA, 1974). Other regulations include federal privacy laws, such as Health Insurance Portability and Accountability Act (HIPAA, 1996), which is required when Medicaid is billed for school-based services; the Children’s Online Privacy Protection Act (1998); and the Protection of Pupil Rights Amendment (1978). Individual states have their own confidentiality and privacy requirements that will need to be applied as well as rules on conducting assessments and treatment. Regulations may require documents of informed consent outlining the nature and possible risks of the services provided, technology employed, and recording (i.e., audio and video) of sessions. Also, the SLP will need to be licensed in the state they reside in as well as the state that the client resides (ASHA, 2020a). The school-based practitioner will need to check both the state’s licensure board and the state’s department of education about their telepractice laws (ASHA, 2020b). For example, some states require that a student’s assessment must take place in person prior to implementing telepractice.
Infrastructure
Since telepractice is conducted remotely via the internet, the infrastructure is vitally important. The infrastructure consists of the video conference platform, equipment, and connectivity. Each of these areas are explained in the following sections, and an implementation checklist noting required and optional telepractice components are provided in Figure 1.
Telepractice implementation checklist.
Platform
The first critical component for conducting telepractice is the video conference platform. Selecting a platform can be a daunting task for a therapist as the number of platforms available have grown substantially. Per ASHA (2016) guidelines, the platform needs to be HIPAA compliant by adequately protecting the privacy and security of protected health information. Therefore, FaceTime, Skype, and Facebook Messenger are not viable options. In contrast, Zoom, Adobe Connect, Google Meet, GoToMeeting, and Webex all are options because they offer a business associate agreement, which is a legal document between a health care provider and a contractor (e.g., Zoom) who might receive access to protected health information. The business associate agreement satisfies the HIPAA regulations and creates a bond of liability between the two parties. Alternatively, some companies have created management systems specifically designed for telepractice.
In addition to the basic features included in most video conferencing platforms, practitioners should consider extra features to enhance the telepractice experience (ASHA, n.d.-c). For example, screen sharing is a must for simultaneously viewing materials during therapy, such as PDFs, YouTube videos, Google Slides, PowerPoint slides, and virtual books (e.g., Vooks; Vooks, n.d.). With screen sharing, students can use boom cards during telepractice sessions (Boom Learning, n.d.). Boom cards are digital activities hosted on the Boom platform. Teachers can create or purchase activities that allow students an opportunity to interact and self-check while working on a variety of goals, such as articulation, pronoun usage, or “wh–” questions. Other basic features that make online learning successful are chat boxes, integrated games, and an interactive whiteboard. Some platforms offer the option to record sessions so that caregivers and/or teachers can watch the session later leading to increased engagement and collaboration.
While the platform and features of the video conference system are vital, SLPs are also responsible for bookkeeping tasks. Some platforms provide integrated electronic medical records systems for scheduling, billing, and goal/progress tracking. Some electronic medical record systems can sync with Google Calendar offering convenience and automated therapy reminders. You can find comparison charts curated by experienced SLPs in social media as well as in ASHA’s Telepractice Special Interest Group.
Equipment
Next, it is important to secure appropriate equipment to deliver the telepractice sessions (ASHA, n.d.-c). This includes a computer with quality audio and clear video (Cason & Cohn, 2014). A second monitor can be useful so that the SLP can see the student on one screen while viewing the student’s goals and documenting the student’s accuracy on another screen. A headset, especially one with a noise-canceling option, will aid both the therapist and the client in hearing and understanding each other better. An external microphone, including those attached to a headset, can allow for clearer speech to be heard while reducing sound echoes. A document camera is useful for displaying hard copy materials during assessment (e.g., testing materials) and treatment (e.g., visual supports) sessions. For example, when conducting assessments via telepractice, the practitioner can use a document camera to display the hardcopy stimulus book. Finally, the student should be seated at an appropriately sized table or desk to ensure proper positioning and breath support.
Internet connectivity
Reliable internet service is crucial for establishing a good internet connection during tele-practice sessions (ASHA, n.d.-c; Hines et al., 2019). Before selecting a room at the end of a hallway or a small office location, determine if adequate internet connectivity can be established. Speech-language pathologists can locate minimum bandwidth speeds from the platform provider and test internet speeds using free online internet speed test apps. Suggestions for enhancing internet connectivity are to plug the computer directly into the router or, if using Wi-Fi, to set up the computer as close to the router as possible to ensure faster speed and a clearer picture. Tips for improving bandwidth and internet speed on a device are to close all other windows and applications on the user’s desktop, clear the cache, and reduce the number of additional devices using the Wi-Fi signal. If internet speed remains a problem, additional measures may be necessary, such as using a Wi-Fi hotspot.
Student selection
Prior to setting up a telepractice session, SLPs need to determine if a student is an appropriate candidate for telepractice (Cason & Cohn, 2014). Student characteristics, such as hearing, vision, behavior, and communication needs, may affect a student’s ability to benefit from telepractice (ASHA, n.d.-c). During the initial intake, the SLP can determine if there are student-specific challenges within the online service delivery model (Ben-Aharon, 2019). For some students, an indirect telepractice model may be required in which the SLP provides consultation to guide and direct someone at the school who works directly with the student to implement the intervention. For example, an SLP may direct a preschool teacher to expand a student’s comments during a pretend play activity in the kitchen center for a student with autism who will not attend to a computer screen. For other students, accommodations may be necessary for support. For example, an e-helper may assist during the therapy session to redirect the student’s attention or may reposition the student and computer to limit distractions. In addition, some therapy techniques to address specific student needs may be difficult to provide without being face-to-face, such as oral-motor interventions for students with apraxia.
E-helper
Technology confidence, systems, and support may be a challenge with telepractice. While most telepractice platforms are easy to use, some students may not be able to access them independently. An e-helper should be designated and trained in the school setting to provide technology assistance (Grogan-Johnson et al., 2010). Training and support may also need to be provided to caregivers if services are being provided in the home setting.
Getting Ready for Telepractice Sessions
Electronic welcome packet and trial run
To get started, the SLP can share an electronic welcome packet and complete a trial run. The welcome packet contains a brief overview of telepractice, provider’s biography, contact information, and important weblinks. The packet could also include a brief video for the student and e-helper. The video could briefly introduce the SLP along with the technology and information about troubleshooting. The welcome packet can be personalized for individual students. The welcome packet can be created on a free platform such as Google Documents or Google Slides. Settings can be adjusted to limit who views and edits the document.
Speech-language pathologists should conduct a trial run with the student prior to the first session. The trial run offers an opportunity to confirm that the SLP and student’s equipment is working as expected and to demonstrate how services are provided using the online format (Hines et al., 2019). This informal session is a great time to start building rapport with the student. In addition, SLPs can offer recommendations of environmental changes to aid the student’s attention, such as positioning the student to limit distractions or adding light to brighten the environment so the student may be seen more clearly on camera.
Considerations for assessments
Students using telepractice may need to complete assessment measures for evaluations, progress monitoring, and data collection. When assessing students via telepractice, SLPs should determine if the selected standardized measures have been validated for online administration (ASHA, n.d.-a). Many publisher’s websites provide evidence of equivalence for face-to-face administration and telepractice. Some standardized evaluations may be conducted using web-based assessments through online test providers, such as Q-Global (Pearson, n.d.). Before conducting assessments, SLPs will need to determine how the receptive portion of the test will be administered. For example, the SLP can grant the student remote mouse control so the student can select responses with the mouse cursor or can have a second camera positioned behind the student to watch the student as they point to images on the computer screen. Alternatively, the e-helper can verbally label where the student points. Speech-language pathologists should use their clinical judgment to determine if any factors during the assessment did not support the use of normative data (e.g., response time, need for repetition, quality of audio, and visual feeds). Additional assessment considerations can be found in ASHA’s assessment via telepractice resource (ASHA, n.d.-a).
Key Elements for Ongoing Sessions
Checklists
Checklists can be used to ensure that schools, e-helpers, and students are ready for each therapy session. The student-specific list should include materials needed for the session, procedures for troubleshooting audio/video issues, and strategies for improving internet connectivity. The SLP should communicate with the school or caregivers to determine if an e-helper will need to be present during the sessions and outline the duties that will be expected (e.g., provide instructional support during the session or redirect student’s attention). A sample telepractice session checklist is provided in Figure 2.
Telepractice session checklist.
Establishing rapport
Rapport is traditionally established between SLPs, children, and families through feelings of interest, sensitivity, and concern. To build rapport online, Akamoglu et al. (2018) identified three strategies: (a) provide opportunities to get to know each other, (b) make personal connections, and (c) communicate with caregivers. Speech-language pathologists should ask about student’s interests when establishing rapport online. Sharing some interesting personal information with the student can also help establish a connection. To increase communication with caregivers, SLPs should use open lines of communication, including text messages, phone calls, and emails to solicit parent input. While the online communication dynamics of telepractice may require targeted rapport building, the extra time and effort can result in increased student and caregiver buy-in.
Collaboration with school staff
As the SLP is not physically present in the school building, extra effort is required to establish effective collaboration between the SLP and student’s teacher to support the student’s speech-language needs in the classroom. Speech-language pathologists may have to utilize e-mail communication, video conferencing, and e-helper assistance to establish and maintain consistent communication between the SLP, the student’s teacher, and caregivers (Grogan-Johnson et al., 2011).
Conclusion
Despite some continuing concerns regarding implementation issues, the use of telepractice is not only increasing in use, but the rate of telepractice increased sharply in 2020 due to school building attendance limitations as a result of the recent school closures (ASHA, 2020a; Cason & Cohn, 2014). Speech-language pathologists who deliver interventions via telepractice create learning experiences using technical, procedural, interactive, and virtual preparations (Towey, 2012a). However, few SLPs have had formal training in this online service delivery but instead have learned on the job (Tucker, 2012). To learn more about telepractice resources and training opportunities (e.g., online webinars, published articles, and collaboration with peers), readers are encouraged to visit ASHA’s telepractice website and other online resources provided in Table 1.
Online Telepractice Resources.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
