Reaching the Neediest Preschoolers Not surprisingly, providing telepractice services to preschoolers can be tough. How do you captivate a child who can’t sit still? Here’s what one SLP learned is crucial to effective Web-based early intervention. Features
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Features  |   February 01, 2014
Reaching the Neediest Preschoolers
Author Notes
  • Tracy Sippl, MS, CCC-SLP
    provides services through her private practice, Pediatric Communication Therapy (Seymour, Wis.), and remotely through Cumberland Therapy Services, for whom she blogs at http://cumberlandtherapy.wordpress.com. She is an affiliate of ASHA Special Interest Group 18, Telepractice. ·ptsipp@yahoo.com
  • Angela Hein Ciccia, PhD, CCC-SLP
    is assistant professor of communication sciences in the Department of Psychological Sciences at Case Western Reserve University. She is an affiliate of ASHA Special Interest Group 2, Neurophysiology and Neurogenic Speech and Language Disorders, and associate editor of SIG 2 Perspectives. ·angela.ciccia@case.edu
Article Information
Special Populations / Autism Spectrum / Early Identification & Intervention / Telepractice & Computer-Based Approaches / Features
Features   |   February 01, 2014
Reaching the Neediest Preschoolers
The ASHA Leader, February 2014, Vol. 19, 42-48. doi:10.1044/leader.FTR1.19022014.42
The ASHA Leader, February 2014, Vol. 19, 42-48. doi:10.1044/leader.FTR1.19022014.42
I sat at my laptop computer grinning at “Eric,” a dark-haired, 3-year-old boy located 8,000 miles from my home in Seymour, Wis. As I smiled outwardly at this boy—who had been diagnosed with severe autism spectrum disorder— I roiled inwardly, wondering how on earth I was going to engage him in speech-language treatment over a computer.
We all know that the earlier we provide services to children with developmental delays, the better they do (see article on page 48). Still, I couldn’t help but question whether telepractice treatment could work for such a young child with profound needs. Without remote services, however, Eric would have received none of the early speech-language intervention he so desperately needed. Two communication problems needed immediate attention: He couldn’t request items he wanted or needed, nor could he understand safety commands. Eric tended to run off unpredictably at home and in public (typically in parking lots!), so it was critical that he learn to heed requests to stop.
Eric’s mother was living in Boston at the time, and Eric moved to live with his father in the Philippines, where he benefited from a variety of early intervention services, with the exception of speech-language treatment. That’s when Eric’s parents pursued the telepractice option with my employer, Cumberland Therapy Services, which led them to me.
This experience was my first serving someone so young from such a distance, and the prospect was daunting. For one thing, Eric could not sit in one place for more than 10 seconds. For another, the father struggled to hold the child on his lap during treatment because Eric appeared hypersensitive to touch. It was also difficult to get him to attend to the computer screen to perform tasks. He was easily distracted, and our session was late in the day, so he was already tired and maxed out from earlier treatment sessions.
So, after that first challenging session, I focused on how I was going to make remote treatment work for this very young child. I realized that to serve him successfully, I needed to restructure my usual approach to telepractice to better cater to his age, needs, attention level and interests. This restructuring would require that I effectively enlist Eric’s parents in his treatment and that I change my typical handling of evaluation and scheduling.
I worked out these changes over the course of Eric’s treatment, ultimately making it a success. Here is what I learned.
Evaluating the Client
Eric came to me with a firm diagnosis of severe ASD. Now I needed to assess how his speech and language capabilities were affected. I immediately ran into the two major challenges of remote evaluation of children age 0 to 3: First, there are no speech-language evaluation instruments standardized for use via telepractice, and second, maintaining the child’s attention enough to conduct an evaluation during a single telepractice session is close to impossible.
So, you need to be creative and employ one of the following options:
  • Travel to the client’s location or designate a local SLP to do the evaluation and provide you with the results.

  • Obtain a language sample from the client through general conversation, by asking the client to create a story about a picture you are sharing on your desktop, or by transcribing video footage of the client interacting with others in his or her environment.

  • Have the parents or caregivers record videos of the client during regular routines, whether in school or at home (preferably both), to analyze conversational language, pragmatics and play skills. This approach allows you to observe meaningful conversation in a natural context.

  • Evaluate the child by using identical copies of tests: one located at your office and the other at the child’s school or home. You and your e-helper (an adult, such as a parent or educator, who assists the child onsite) are viewing the same material at the same time. It should be noted in the report that the evaluation was conducted via telepractice and that the interpretation is based on this nonstandardized administration. Also, when considering the child’s scores, keep in mind that the tests used were not standardized for telepractice purposes.

Remember that, ultimately, video footage and language samples provide invaluable information, regardless of your primary evaluation approach. This is the system I used to better understand and evaluate Eric's communication skills.
Scheduling the Sessions
One of my major struggles with Eric was handling his extreme hyperactivity, which was exacerbated by the late hour of our remote treatment sessions: 7 a.m. my time, which for him in the Philippines was evening. We’d selected this time based on his parents’ schedules, but it was soon clear that he was too mentally and physically exhausted to perform well then. So my first step was switching the session to 7 p.m. my time, which was morning for him.
Here are some other helpful scheduling suggestions to keep in mind when scheduling such young clients:
  • Schedule a practice session or two with your e-helper. Before formally starting treatment, I show the e-helper the types of activities I will use, and we discuss how we’ll work together and agree on behavior expectations for the child. I find that it works best to incorporate existing school- or home-based behavior-management systems into treatment.

  • If you are working with an early childhood or pre-kindergarten program, provide services to those students right after they arrive for the day (before they are entrenched in playing and other activities).

  • For this age group, one-to-one treatment works best, but you could work with two students provided you have a number of fast-paced activities that quickly move between them.

  • If you are working with two youngsters, be sure to have your e-helper sit between (and a bit behind) the two to avoid any additional distractions.

  • Students age 3 to 4 tend to be very wiggly. Scheduling shorter sessions and increasing the frequency works well.

  • If you are providing services to students in a preschool setting, I strongly recommend “pull-out” telepractice for those working on articulation skills. However, if the disorder is language-based and there are three or more students in one classroom, team teaching can be the most efficient approach.

Coaching the Caregivers
When treating very young children, nothing gets better results than highly engaged and involved caregivers. In telepractice situations, they are your critical treatment aides, both during and between sessions. When I was treating Eric, however, what became apparent was that most caregivers do not naturally know what is required, and need “parent coaching” to help their charges more effectively.
In Eric’s case, I began the coaching process by having the parents videotape their daily interactions with him. These revealed that they were aware of their son’s difficulties and in tune with his communication needs. However, even though Eric appeared quite bright, his parents were frustrated by his lack of language comprehension, inability to follow directions and limited expressive skills. Based on these findings, I provided Eric’s parents with information about expressive language development and explained that their expectations appeared to be beyond his current capabilities (determined by his age and diagnosis).
Next I took the language and vocabulary skills they wanted him to learn and broke them down into smaller steps that they could practice with him between treatment sessions. (See my ASHAsphere blog post for more specifics on these steps. Other ways I ask parents to support their children’s treatment include:
  • Assigning homework, which boosts progress and allows parents to keep abreast of what is being addressed in treatment.

  • Speaking with parents often (when possible), which helps me gain insight into a child’s behavior and motivation, and gives me a glimpse of life at home—we all know children’s performance can be significantly affected by what happens at home. For example, if the child is feeling ill or did not sleep well the night before, he or she may be less compliant during treatment.

  • Providing parents with short, specific progress notes besides the usual paperwork to help them feel connected and updated on the child’s progress.

Materials
Parents aside, no intervention with preschoolers—or any young children—will work without a strong emphasis on play and fun. I use colorful, animated PowerPoint games and slideshows in my treatment. One key resource is PBSkids.org, which features coloring pages, tic-tac-toe games, and other engaging stories and activities you can easily incorporate into telepractice. To motivate students, I often leave the last five minutes of sessions open so that students play a game from my Google desktop. The games I provide assist in the generalization of language skills in connected speech.
Also, given that children this young tend to wiggle more and enunciate less, I require that they use an “in-the-ear” headset with an attached microphone, rather than a stand-alone microphone that loses their vocalizations if they’re not close to it. By using these types of strategies, I was able to make substantial progress in Eric’s remote treatment.
After treatment, both his parents commented that they felt “included” in the intervention and empowered by knowing the treatment goals being addressed. Each session presented its own set of challenges, but we made substantial progress thanks to his parents’ help and to our scheduling flexibility.
Before treatment, Eric was unable to request such simple items as juice or a toy, and he almost never heeded verbal commands. After just eight weeks of remote treatment, he complied with verbal directions— such as “stop”—35 percent of the time, and he successfully requested items 50 percent of the time. He’d come a long way, and his speech—and personal safety— continue to improve every day.
Catching Underserved Kids Early with Remote Screening: Tele-screening in primary care may be one solution to the conundrum of reaching children from low-income families in the critical first years.

It’s a problem that’s well-known but difficult to tackle: Children from lower-income, ethnic-minority families are less likely to receive early intervention for developmental disabilities.

Why? Provider behavior is one factor: Primary care providers are less likely to ask racial/ethnic and non-English-speaking parents about developmental red flags, according to one study—a survey published in 2011 in Pediatrics. Parents’ behavior is another factor: For example, children whose mothers are well-educated tend to be diagnosed earlier with autism spectrum disorder, even when presenting with less severe forms of the disorder, compared with children of lower socioeconomic status, according to recent data presented in the Journal of the American Medical Association.

These disparities are reflected in the low use of early intervention services reimbursed through Medicaid: Just 1.8 percent of children younger than 3 years receive Part C services and 5 percent of preschool-age children receive Part B services, according to U.S. Department of Education data (see sources online). Given that 17 percent of U.S. children have a developmental disability, why are these usage rates so low, and why does low use of early intervention services persist in the Medicaid population?

The reasons are complex. For families, problems include lack of transportation, time and health insurance. Physicians often have insufficient time to complete developmental screenings, limited access to nonphysician professionals and staff to complete screenings, and limited resources to monitor referrals.

One solution our research team is exploring is helping primary care practices add developmental screening via telepractice. To test this system, we completed a feasibility study on the use of telepractice to screen for speech-language and hearing disorders in an urban community health clinic network that provides medical services in low-socioeconomic neighborhoods. The telepractice screenings were conducted via videoconferencing in conjunction with scheduled pediatric well-care visits, reducing the need for additional appointment times.

Clinicians conducting the screening gave parents the results immediately. The pediatrician was also immediately notified of the results via a written form that was faxed or scanned.

A speech-language pathologist and audiologist conducted the telepractice screenings, with speech-language pathology graduate clinicians facilitating onsite. The speech and language screening included a brief parent interview; the Receptive-Expressive Emergent Language Test-Third Edition (REEL-3) or the Screening Kit of Language Development (SKOLD), depending on the child’s age; and the articulation screener from the Preschool Language Scale-3. The hearing screening included PC-based typanometry and distortion product otoacoustic emissions testing or a PC-based behavioral audiometry.

We screened 411 children, ages 0 to 7, with 36 percent of them younger than 3. Results indicated a higher prevalence of speech and language delay than would be expected based on national prevalence estimates (36 percent average failure rate in this study versus 2 to 19 percent, depending on the disorder). However, this result was not surprising, given that the participants were recruited from a higher-risk group. The identification rate for the hearing screening was roughly equivalent to national prevalence estimates (2 to 15 percent depending on the client’s age at testing).

Afterward, families reported high satisfaction with the telepractice screening, including the quality of the audio and video equipment, and high comfort level using the computer. They also preferred receiving the telepractice screening during a well-care physician visit to navigating an additional appointment with a specialist.

Our results were encouraging and we had a large number of participants, but the number was too small to generate specific practice guidelines. In future studies, children who fail the screening need to be followed through to full assessment to determine the true ability of telepractice screenings to correctly flag children for delays or disorders.

Despite these limitations, our study suggests that telepractice is a feasible, likely cost-effective way to provide screening of high-risk children for speech-language and hearing delays and disorders. Although many questions about population-specific diagnostic and intervention techniques remain unanswered, telepractice is at the forefront of solutions that can improve the lives of our youngest clients.

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February 2014
Volume 19, Issue 2