Speech-language pathologists at Kent State University, in Kent, OH, are working to prevent a profession-wide shortage from affecting students in rural schools by testing a telepractice program for speech and language therapy.
The pilot program is a small part of the Ohio Masters Network Initiatives in Education (OMNIE), a professional development initiative for speech-language pathologists in the state sponsored by the Ohio State Department of Education, which is funding the teletherapy research. "This is the first project that's been supported at the state level and where there's been research on outcome," said Robin Alvares, PhD, CCC-SLP, project coordinator for the OMNIE Telepractice in Speech-Language Pathology Project at the Kent State School of Speech Pathology & Audiology.
The project came to Kent State by way of Susan Grogan-Johnson, PhD, CCC-SLP, director for the telepractice initiative and an assistant professor at the university. As a member of the OMNIE task force, she met with the state Department of Education to discuss issues pertaining to the statewide shortage. Having heard about telepractice programs used by private contractors in other states, she mentioned it as a possible alternative. The committee enthusiastically accepted the idea, particularly Ohio Department of Education superintendent Lou Staffilino.
"I had heard a little bit about it and thought it might be a reasonable solution," Dr. Grogan-Johnson said. "We just put one foot in front of the other. We jumped in because we had to have it ready to go [by fall 2007]."
Drs. Alvares and Grogan-Johnson and Lynne Rowan, PhD, CCC-SLP, director of the Kent State School of Speech Pathology & Audiology, set up the pilot program to test the feasibility of the delivery method and to determine whether students made the same kind of progress using teletherapy as they did in a traditional model. Currently, they are evaluating the data they collected to determine if the children made similar amounts of progress in both therapy models. "We're not done with the analysis, but we think it's going to show that," Dr. Grogan-Johnson stated.
Four rural school districts in Western Ohio were selected as pilot sites. Students who obtained parental permission to participate in teletherapy agreed to receive traditional face-to-face therapy for the first part of the school year and teletherapy for the other half. "We used a split design because we thought we could guarantee benefit but weren't sure," she said. "There's not much research on the efficacy of children having speech-language therapy services via telepractice versus face-to-face."
Since the clinicians didn't have experience with teletherapy or extensive technological knowledge, they quickly set about learning whatever they could about the practice in the scarce professional literature available. They read published research from other professions, particularly psychology and counseling, and consulted with colleague Mark Krumm, PhD, an audiologist at Kent State who has conducted research on teletherapy in audiology.
Dr. Grogan-Johnson also sought a more hands-on research approach by observing some teletherapy sessions at Integris Health Systems, a hospital that provided services to children in rural areas. "I needed to see telepractice in action," she said. "I was thinking about how we could make it curriculum-based and more connected to the child's education."
She and Dr. Alvares sought the advice of Dr. Krumm and Mary Tipton, MEd, director of Technology and Distance Education at Kent State, to select the software for the program. They chose basic meeting software from Polycom Inc. Though they are satisfied with its features, they eventually would like to pursue software designed specifically for speech and language therapy. "It's a fantasy that one day we'll get to design our own software," Dr. Alvares said.
Most of the children chosen to participate in the pilot program presented with varying degrees of articulation, phonological and language impairments. One student presented with a fluency impairment, and another had a mild cognitive delay. The clinicians initially excluded from the pilot study preschoolers, children with significant cognitive impairments, and children with severe autism because they were unsure how these populations would respond.
After completing the pilot program, they changed those restrictions for the upcoming school year. "We're adding in preschoolers and children with some behavior problems and significant cognitive impairments," Dr. Grogan-Johnson said. "They have at least some beginning skills with the computer, so we think they will be able to do it."
Teletherapy sessions differ very little from the approach used by most school-based clinicians, according to Dr. Alvares, who acted as the "e-SLP" for the sessions. "It isn't that different from a typical therapy session, except I'm not physically there."
Sessions followed the goals and objectives of a child's individual education plan (IEP). Typical therapy exercises required little alteration. "Sometimes the kids like doing low-tech stuff, like playing Battleship on paper," she said. "I'd show them a picture or tell them a word or sound to make, and they got to take a turn."
Technology plays a more active role if Dr. Alvares and the child engage in data sharing. They may access a Web site or computer program and use telepractice software to shift control of the onscreen cursor back and forth when they take turns.
Similar to face-to-face therapy, the e-SLP informs the child of the session goals and what will be worked on at the beginning of the session and moves onto different activities. "Robin might be playing a game or working on a storybook writing activity, but it maintains therapeutic practice," Dr. Grogan-Johnson explained. "It's just made to be a little bit more fun or similar to a curricular activity through the games or computer application they're sharing."
An "e-helper" escorts the child to and from therapy and manages the on-site materials. This individual, who acts as an assistant during therapy, may hand out stickers as rewards or distribute a worksheet the e-SLP has faxed over, but the e-helper does not participate in the actual therapy.
The e-helper cannot be afraid of technology and must be reliable, able to follow a schedule, and be responsible for learning the basic skills of the software and webcam to intervene in the case of a technological problem.
Student reaction to the program was overwhelmingly positive. Only one of the 37 students did not want to participate in the program the following year. "I thought the novelty would wear off, but it didn't," Dr. Alvares said. "The students really seemed to enjoy it."
"There's something about wearing that headset and looking at Robin across the computer screen. They seem to be more engaged and attentive," agreed Dr. Grogan-Johnson.
Though the clinicians do not have a complete set of recorded data yet, they already have received positive feedback about the program from faculty and administrators who felt teletherapy was more consistent than face-to-face sessions and required more attention and engagement on the part of the student.
One of the drawbacks noted in the pilot study results was a lack of communication and connection between the e-SLP and classroom teacher. "We do not have the same collaboration with faculty, and we don't feel the same sense of being part of the educational team," Dr. Grogan-Johnson said.
While Dr. Alvares maintained regular contact with the school principal by e-mail, she found that some teachers preferred conveying messages through the e-helper. This was problematic because the aide did not have speech and language training.
She plans to address the issue this school year by finding better ways to communicate with teachers. "I'm going to meet with them and maybe do an inservice so they have a face to go with my name. That might make them more comfortable approaching me," she said.
The clinicians communicated with parents by e-mail, phone calls and written notes. Parent reaction to the program was extremely positive. Most parents rated the program as "above average" and praised their children's progress.
This year, the program will have a more rigid structure and undergo several other changes to provide more measurable results. The students will remain in teletherapy the entire year. "We are developing measures to take baseline and end-of-year data to gauge progress," said Dr. Grogan-Johnson. "We'll compare that to children who are in face-to-face situations."
The clinicians also plan to study a group of students with articulation impairments who will receive teletherapy services for the entire school year and compare them to a group receiving face-to-face therapy enhanced with the same computer-based programs. These groups will be compared to children who receive traditional face-to-face articulation therapy.
"We can't randomly assign our students to delivery methods, but we can do a direct comparison among the three groups to look at amounts of progress and consistency of services," she explained. "It's probably as close as we can get to a tightly controlled study in the real world."
If successful, the teletherapy program may be an affordable solution for rural and inner-city school districts facing shortages of speech-language therapy services. Teletherapy also could provide access to specialty consultation in areas such as augmentative and alternative communication (AAC) and fluency. "Larger districts might have a whole AAC team, while smaller districts might only have one or two kids with AAC needs," Dr. Alvares said. Teletherapy would allow rural school districts to get services from the most qualified professionals rather than from speech-language pathology assistants.
She and Dr. Grogan-Johnson hope their research will help to determine which student populations derive optimal benefit from the approach. Teletherapy may allow school speech-language pathologists to devote more resources to students who need services on site. They plan to continue research in this field thanks to the support they have received from the state, their university and the school administrators.
Alyssa Banotai is a Senior Associate Editor at ADVANCE.