No Student Left Unserved Yes, telepractice can work with our most behaviorally challenged students in schools. Here’s how. Features
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Features  |   December 01, 2014
No Student Left Unserved
Author Notes
  • Michelle Boisvert, PhD, CCC-SLP, is part-owner and head clinician at WorldTide, Inc. She is an affiliate of ASHA Special Interest Group 18, Telepractice. michelleb@worldtide.com
    Michelle Boisvert, PhD, CCC-SLP, is part-owner and head clinician at WorldTide, Inc. She is an affiliate of ASHA Special Interest Group 18, Telepractice. michelleb@worldtide.com×
Article Information
School-Based Settings / Telepractice & Computer-Based Approaches / Features
Features   |   December 01, 2014
No Student Left Unserved
The ASHA Leader, December 2014, Vol. 19, 48-52. doi:10.1044/leader.FTR2.19122014.48
The ASHA Leader, December 2014, Vol. 19, 48-52. doi:10.1044/leader.FTR2.19122014.48
A rural New England school had a problem: It couldn’t find qualified speech-language pathologists to treat its students, all of them on the autism spectrum. School administrators examined all their options and decided on the one they deemed most cost-effective and efficient: services via telepractice.
The school approached our company, WorldTide, Inc., based on a recommendation from a former colleague. Now we faced the challenge of customizing our telepractice services to the wide-ranging speech-language needs of these students, who have moderate to severe autism spectrum disorder with varying functional levels and intellectual abilities. All the students referred by the school have Individualized Education Programs for speech and language services, including goals for social pragmatics and for receptive and expressive language.
Though verbal, these students require extra support to help them with behavioral and communication challenges. They receive instruction in small classes that include a primary educator and several paraprofessionals. Some have one-to-one aides. So here was the crux of our task: How were we going to engage a group of students with such prominent behavioral difficulties? Staff at their school were concerned that telepractice might not work with them because of—for example—inattention, acting out and overstimulation.
For guidance on this question, we turned to the literature—but found a dearth of research on use of telepractice with this population. We did find, however, that other technological strategies appear to work well for students with behavioral and communication challenges: Studies indicate that virtual reality, computer-assisted technologies and video modeling benefit their communication and interaction, life skills, social learning and imitation (see sources).
Informed by this research, the onsite educational staff and the treating off-site clinician (me, based at WorldTide) collaborated and crafted strategies to best serve these students remotely. Along the way we tested and modified the strategies to see what worked best. Here’s what you need to know if you want to launch a program like this.
  1. Establish a team. Before starting services, we at WorldTide met at the school with the director of special education and classroom educators. During this meeting, we explained how telepractice works and fielded questions. The onsite professionals saw examples of telepractice and experienced a mock session, giving them a first-hand look at the experience their students would have.

  2. Identify concerns or barriers. During and after the meeting, we urged educators to voice any concerns: Mostly they worried that students would misbehave or fail to pay attention. Others feared the technology might overstimulate students. Based on these concerns, we started the program armed with proactive strategies such as visual scaffolding, built-in rewards and highly organized sessions. Also, allowing school staff to discuss problems and solutions with us bolstered their acceptance of our program.

  3. Plan and prepare. Our staff trained school staff on the hardware and software needed for telepractice: a desktop computer, speakers and a webcam with built-in microphone. We use the GoToMeeting Web conferencing system because it offers the right mix of security measures and ease of use. Before each session, the clinician sets up the virtual meeting and the offsite team logs in. The students see and hear the clinician on their screen and access prepared material through the screen-sharing option. Our clinicians use headsets to reduce audio feedback.

  4. Send reminders daily. To increase student attendance, we e-mail morning appointment reminders to administrators, classroom educators and paraprofessionals on treatment days. The e-mail includes a direct link to the virtual meeting room, notification of resources uploaded on a shared site, and the clinician’s contact information in case a student cannot attend.

  5. Make troubleshooting easy. We often spend the first few minutes of sessions troubleshooting, especially after vacations interrupt treatment. Our “tech-check” splash screen walks onsite professionals through our three most common tech issues:

    • How to turn on the webcam.

    • How to turn on the microphone and speakers option.

    • How to place and size the webcam presentation windows on the screen.

  6. Provide activity schedules. We use a visual schedule at the beginning of and throughout each session to introduce activities, help students plan for treatment, provide visual warnings for transitions, and understand expectations. Images represent the activities sequentially. Each image links to the activity for quick access and organization. Students check off activities on the visual schedule as they complete them.

  7. Ensure material can be modified. We use materials that permit flexibility, allowing us to change up activities quickly according to students’ skill levels or behavior at the time. These include static materials (such as PDFs), virtual manipulatives, graphic organizers, stories and videos. We don’t use websites and games with lots of animation and sound to avoid overstimulating students and delays in loading.

  8. Build in choices and motivators. We allow students to choose various activities, such as a preferred book or video and/or method of answering questions (narrative or written). Students choose a highlighter or marker for annotation, and motivators like listening to music, watching a video, reading a book or drawing. We also provide instructional breaks for rewards and rejuvenation and use visual timers to ease transitions. To engage students, we use movable pictures and spotlights, verbal encouragement, high fives, e-stickers on pages and electronic tally boards.

  9. Scaffold instruction. We customize each lesson so that the student gets the right mix of needed support and opportunities for independence. We present material one page at a time and provide tools as needed. Students respond well to mini-lessons, with skills presented in verbal, visual, tactile and written formats and icons used to support all text and auditory information. Students also respond well to editable graphic organizers like t-charts and bubble charts and to positive reinforcers like e-stickers and high fives after completing lessons.

  10. Present material consistently. We use interactive whiteboards or PowerPoint to create templates for presentation of our visuals and tools. Viewing material in the same format reduces stress on students because it offers them consistency of expectations and learning formats.

  11. Keep the Web layout fixed and uncluttered. Our webcam presentation windows sit at the top of the computer screen, right under the actual webcam. This positioning promotes eye contact and natural facial and body positioning. We also hide all toolbars, chat boxes and control panels to maximize screen space and minimize distractions.

  12. Support carryover into the classroom. Our remote SLP constantly consults with the students’ classroom educators, linking vocabulary and self-help, social, and language skills to the curriculum. Onsite staff observe telepractice sessions and print out select behavior schedules, visual prompts and electronic material to use in the classroom that reinforces what students learn in treatment.

As evidence that these telepractice strategies work, all students receiving our services show documented progress with verbal output, social communication, and receptive and expressive language. Administrators, educators, paraprofessionals, caregivers and the students themselves report positive experiences with the program. None of this would be possible, however, without close collaboration among the onsite staff, the off-site clinician and the students.
To make a program like this work, you also need to ramp up gradually, closely monitor students’ responses to interventions and make adjustments accordingly. We still have much to learn about effective telepractice, but our experience points to a promising future for telepractice services for students with autism spectrum disorder.
Telepractice Don’ts
  • Don’t rely solely on game-based activities. When choosing material, consider usability and content. Games, websites and apps that are highly automated may not allow clinician control, interaction and modification.

  • Don’t simply connect via videoconferencing and call it telepractice. Clinicians must be trained on the technologies, security measures and clinical approaches needed to provide high-quality telepractice services.

  • Don’t expect sessions to be glitch-free. Some sessions will not go as intended, so be ready to triage hardware and software issues. One strategy is to use two computers, one for treatment content and the other for streaming video and audio. One can serve as a backup if the other goes down. Also be ready to use tangible materials, like flashcards, as needed.

  • Don’t go it alone. Collaboration with administrators, educators and others supporting your client is essential to any telepractice program, ultimately determining its success. Teamwork helps ensure that services are consistent and that students transfer skills.

What Makes a Client a Better Telepractice Candidate?

It’s up to the treating clinician to determine if telepractice is right for a particular client. And the guidelines are fairly basic—the candidate should ideally be able to:

  • Sit in front of a monitor and attend to a remote clinician.

  • See, hear and understand materials presented remotely.

  • Understand and follow instructions.

  • Operate the input devices, such as the keyboard, mouse, trackball or touch screen.

  • Participate willingly.

  • Have a requisite level of family or caregiver support.

  • Access technical resources if and when required.

Plenty of clients, however, might not meet all these criteria and still benefit from telepractice services—with some modifications. For example, students with low vision could access content via enlarged images and changes in screen contrast and brightness. Additionally, students with reduced cognitive functioning could process material when presented in small chunks. A student’s candidacy for telepractice services depends more on the program’s resources and onsite helpers than on the severity or type of disability.

Sources
American Speech-Language-Hearing Association. (2014). Professional Issues: Telepractice. Retrieved from:
American Speech-Language-Hearing Association. (2014). Professional Issues: Telepractice. Retrieved from:×
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Aresti-Bartolome, N., & Garcia-Zapirain, B. (2014). Technologies as support tools for persons with autistic spectrum disorder: A systematic review. International Journal of Environmental Research and Public Health, 11(8), 7767–7802. [Article] [PubMed]×
Banda, D. R., Grimmett, E., & Hart, S. L. (2009). Activity schedules. Teaching Exceptional Children, 41(4), 16–21.
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December 2014
Volume 19, Issue 12