The Multi-faceted Implementation of Telepractice to Service Individuals with Autism

Recent Advances of Telepractice for Autism Spectrum Disorders in Speech and Language Pathology

Telepractice or teletherapy is defined as the means of service delivery via technology-based platforms that allow long-distance interventions across populations, age spans, and geographical locations. Specifically, telepractice capitalizes on communication technologies such as online modules, videoconferencing, and computerized software programs, in servicing populations with communication challenges. Notably, telepractice has emerged as a potentially effective, low-cost, and promising means of conducting and completing online assessment, diagnosis, and intervention sessions for individuals with autism spectrum disorders (ASD). Moreover, telepractice allows the inclusion of parents, caregivers, and educators as potential facilitators in supporting treatment delivery in populations with ASD. This thematic review article aims to highlight and acquaint practitioners and other stakeholders with relatively recent information regarding the advantages and disadvantages of the telepractice service delivery model in ASD. Furthermore, the emergence of the COVID-19 pandemic has impacted service delivery in the field of Health Sciences including speech and language pathology (SLP). Consequently, the need to avoid face-to-face therapy sessions, recommended to SLPs as to all health practitioners, resulted in the call for adaptation and adjustment of service telepractice. This paper attempts to answer this call by suggesting supplementing traditional diagnostic and therapy resources with training modules consisting of online materials and use of animated and specially designed programs in SLP intervention with individuals with ASD. Lastly, the paper includes a discussion of research findings in the field, a conclusion, and a take-home message.

Supporting Emergent Bilinguals Who Use Augmentative and Alternative Communication and Their Families: Lessons in Telepractice From the COVID-19 Pandemic

PURPOSE

The purpose of this project was to examine the effect of the COVID-19 pandemic on speech-language pathologist (SLP) service provision for emergent bilinguals who use augmentative and alternative communication (AAC). One prominent issue in AAC service delivery is the efficacy and feasibility of providing AAC services via telepractice. The COVID-19 pandemic intensified this issue as most providers, clients, and families adjusted to remote service delivery models. While emerging evidence supports telepractice in AAC, little is known about the potential benefits and challenges of telepractice for emergent bilinguals who use AAC and their families.

METHOD

Data were collected via a nationwide survey. Licensed SLPs (N = 160) completed an online questionnaire with Likert-type, multiple-choice, and open-ended questions, analyzed using mixed methods.

RESULTS

Findings illustrated a shift in service delivery from in-person to telepractice and hybrid (both telepractice and in-person) models. Overall, child intervention outcomes declined for emergent bilinguals who used AAC during the COVID-19 pandemic, regardless of service delivery format. However, collaboration increased for many providers and families. Qualitative analyses highlighted barriers to AAC service provision for emergent bilinguals who use AAC that were exacerbated by the COVID-19 pandemic, as well as factors that facilitated collaboration and family engagement.

CONCLUSION

These findings suggest that, despite challenges, telepractice or hybrid services may be a promising approach to provide more culturally responsive, family-centered care for emergent bilinguals who use AAC.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20405673.

Expectations and Concerns about the Use of Telemedicine for Autism Spectrum Disorder: A Cross-Sectional Survey of Parents and Healthcare Professionals

Telemedicine has recently been used for diagnosis and interventions inpatients with autism spectrum disorder (ASD), traditionally performed in-person, but little attention has been paid to user expectations prior to its use. The aim of this study is to compare the expectations and concerns of 50 healthcare professionals and 45 parents of children with ASD regarding the use of telemedicine for diagnostic or treatment purposes. Parents have higher expectations for the use of telemedicine as an alternative (p = 0.0223) and supplement (p = 0.0061) to in-person diagnosis of ASD, as well as a supplement to traditional intervention (p ≤ 0.0001). In addition, while they also have greater hope for improvement in family routines (p = 0.0034) and parenting skills in child management (p = 0.0147), they express greater concern about the need for active parental involvement/supervision during telemedicine services (p = 0.015) and changes in the behaviour of the child with ASD during telemedicine services (p = 0.049). On the other hand, healthcare professionals are more concerned about barriers such as lack of devices (p = 0.000), unfamiliarity with the technology (p = 0.000), poor quality of internet connection (p = 0.006), and severity of ASD (p = 0.000). To achieve promising healthcare for ASD patients, the telemedicine service should try to meet the needs and preferences of both healthcare professionals and parents, as well as identify and, if possible, reduce perceived barriers.

Understanding the implementation of telepractice in speech and language services using a mixed-methods approach

Background: Telepractice emerged as a solution to overcome the challenges of access issues in the delivery of healthcare. Telepractice in speech language pathology (SLP) has existed for nearly a decade yet there is a significant knowledge gap with respect to the factors influencing the implementation of telepractice as a routine or long-term, sustained effort. This mixed-methods study aimed to identify implementation factors that influence the provision of telepractice in SLP services.

Method: A mixed-methods study consisting of a scoping review and semi-structured interviews (SSI) was carried out. Articles that described telepractice in SLP were included based on an operational definition of implementation and a set of inclusion criteria.

Results: Data was extracted from 11 studies that were mapped to nine projects in telepractice in SLP. The broad focus areas identified included diagnostics and evaluation, therapeutics and comprehensive assessment, management and follow-up care services. Synchronous/ real-time telepractice methods were always used for the provision of diagnostic testing or when providing therapy services using video conferencing. The ‘ professional-facilitator-patient’ model was used most commonly followed by the ‘ professional-patient’ model.  Barriers for long-term sustainability included inadequate initial capital investment, lack of reimbursement and payment options, low internet speed and bandwidth, resistance and hesitancy to use telepractice from the patient’s end, lack of organizational policies and uniform regulations. Sustainable source of funding, having a dedicated team of professionals and technicians with clear roles and responsibilities, and inclusion of systematic planning facilitated implementation. 

Conclusion: In general, telepractice in SLP was not explicitly guided by implementation science or framework. The use of implementation frameworks ensures systematic planning and feasibility assessment to inform the scale-up of implementation. Therefore, it would be worthwhile for program implementers to consider these aspects when exploring telepractice services.

Understanding the implementation of telepractice in speech and language services for children and adults using a mixed-methods approach

Background: Telepractice emerged as a solution to overcome the challenges of access issues in the delivery of healthcare. Telepractice in speech language pathology (SLP) has existed for nearly a decade yet there is a significant knowledge gap with respect to the factors influencing the implementation of telepractice as a routine or long-term, sustained effort. This mixed-methods study aimed to identify implementation factors that influence the provision of telepractice in SLP services. Method: A mixed-methods study consisting of a scoping review and semi-structured interviews (SSI) was carried out. Articles that described telepractice in SLP were included based on an operational definition of implementation and a set of inclusion criteria. Results: Data was extracted from 11 studies that were mapped to nine projects in telepractice in SLP. The broad focus areas identified included diagnostics and evaluation, therapeutics and comprehensive assessment, management and follow-up care services. Synchronous/ real-time telepractice methods were always used for the provision of diagnostic testing or when providing therapy services using video conferencing. The ‘professional-facilitator-patient’ model was used most commonly followed by the ‘professional-patient’ model.  Barriers for long-term sustainability included inadequate initial capital investment, lack of reimbursement and payment options, low internet speed and bandwidth, resistance and hesitancy to use telepractice from the patient’s end, lack of organizational policies and uniform regulations. Sustainable source of funding, having a dedicated team of professionals and technicians with clear roles and responsibilities, and inclusion of systematic planning facilitated implementation.  Conclusion: In general, telepractice in SLP was not explicitly guided by implementation science or framework. The use of implementation frameworks ensures systematic planning and feasibility assessment to inform the scale-up of implementation. Therefore, it would be worthwhile for program implementers to consider these aspects when exploring telepractice services.

The Evolution of Telehealth From Pre-COVID-19 Pandemic Through A Hybrid Virtual Care Delivery Model: A Pediatric Hospital's Journey

The COVID-19 pandemic transformed care delivery and influenced telehealth adoption by rehabilitation professionals and their patients. The purpose of this paper is to describe a pediatric health system's telehealth services pre-pandemic and how those services were scaled during the pandemic. A secondary aim is to provide a roadmap for the operational delivery of telehealth and rehabilitation services, including transition to a hybrid care delivery model. Findings suggested that telehealth can be rapidly scaled to address patient healthcare needs for an early intervention population during a pandemic. Telehealth use during the pandemic helped ensure continuity of care and likely reduced the risk of exposure to patients and staff to the virus. Benefits included enhanced access to care, and savings in time and money for families. Interestingly, as the pandemic declined, the use of telehealth services declined due to patient preference, with many families opting to request a return to in-person care.

Oral Narrative Intervention by Tele-Practice in a Case with Developmental Language Disorder

BACKGROUND

A narrative requires the integration and management of linguistic and cognitive skills. It has been observed that children with Developmental Language Disorder (DLD) have difficulties in narrating stories. This research proposes an intervention in a case of a child 9 years and 2 months old with DLD, with the aim of improving his oral narrative skills through a retelling task via telepractice.

METHODS

In the evaluation, standardized tests have been used and a 'remembering a story' task, with a story titled The Lost Backpack, elaborated by one of the authors. Narratives were elicited in two sessions, and were transcribed, coded, and analysed using the Child Language Data Exchange System CHILDES Project tool. The participant received a total of 10 sessions through the Skype platform, which included intervention-addressed explicit instruction about the narrative structure and the use of discourse markers to improve cohesion in story retelling.

RESULTS

Significant changes were observed in the retelling of the story at microstructure and macrostructure levels: an increase of the Mean Length of Utterance (MLU), Types and Tokens, specific vocabulary, discourse markers and the recall of events.

CONCLUSIONS

These results demonstrate the effectiveness of intervention in narrative skills through the oral retelling of a story with visual support via tele-practice.

Practitioner and Service User Perspectives on the Rapid Shift to Teletherapy for Individuals on the Autism Spectrum as a Result of COVID-19

Prior to COVID-19, research into teletherapy models for individuals on the autism spectrum was slowly progressing. Following the onset of COVID-19, teletherapy became a necessity for continuity of services, however, research was still emerging for how to translate best practice autism support to the online environment. The aim of this research was to gain insight into the rapid shift to teletherapy for practitioner and service users and the implications for the broader disability sector. Survey responses were collected from 141 allied health practitioners (speech pathologists, occupational therapists, psychologists, educators, and social workers) from four Australian states and territories. A total of 806 responses were collected from service users following an individual teletherapy session. Five themes were identified during the qualitative analysis; (1) technology-love it or hate it; (2) teletherapy as a "new normal"; (3) short term pain, for long term gain; (4) the shape of service delivery has changed; (5) is teletherapy always an option? Data from the quantitative analysis provided further insights into the first two themes. While COVID-19 has brought forward significant advances in telehealth models of practice, what is needed now is to delve further into what works, for who, and in which context, and explore the potentiality, efficiencies, and scalability of a post-pandemic hybrid approach. This will inform practice guidelines and training, as well as information for service users on what to expect.

Implementing Aided Augmentative Communication Systems With Persons Having Complex Communicative Needs

Augmentative and alternative communication (AAC) systems can support communication skills for people with significant developmental disabilities who experience complex communication needs (CCNs). There is a need to tailor best practices in AAC assessment and intervention to create individualized communication systems with this population. In this article, we outline the important components of AAC systems that can be implemented in authentic settings. However, given the limited evidence on AAC interventions specific to people with CCNs, we also identify some priority areas for future inquiry. Among these involve strategies to enhance decision making regarding (a) matching communication mode(s) to learner skills and contextual demands, (b) identifying communicative opportunities and obligations, (c) individualizing aided communication display features, (d) selection of vocabulary specificity, and (e) considering dosage parameters needed to acquire and maintain a communicative repertoire. In addition, we briefly discuss the use of telehealth to enhance intervention capability.

Telehealth and autism: Are telehealth language assessments reliable and feasible for children with autism?

BACKGROUND

Access to timely and appropriate speech-language pathology (SLP) services is a significant challenge for many families. Telehealth has been used successfully to treat a range of communication disorders in children and adults. Research examining the use of telehealth for children with autism has focused largely on diagnosis, parent-implemented interventions, and behavioural interventions involving interactions between clinicians and parents. There is, however, very limited research into the use of telehealth directly to assess or intervene with children with autism. This paper reports the outcomes of a study of telehealth language assessments with primary school-aged children with autism.

AIMS

To evaluate the reliability and feasibility of telehealth language assessments for school-aged children with autism.

METHODS & PROCEDURES

The language skills of 13 children with autism aged 9-12 who attended mainstream schools or support classes were assessed using the Clinical Evaluation of Language Fundamentals-4th Edition. An SLP delivered and scored four subtests of the assessment via telehealth from a remote location. A second SLP at the same location as the child co-scored the online subtests to provide a measure of reliability and delivered the remaining subtests. The local SLP completed checklists in both conditions to provide observations regarding behaviour. Parent feedback was elicited via survey.

OUTCOMES & RESULTS

There was strong interrater reliability between the telehealth and face-to-face conditions (correlation coefficients ranged from r = 0.919 to 0.990 across the subtests and Core Language Score) and good agreement between clinicians on all measures. Analysis using the Wilcoxon Signed Rank test indicated no significant differences in children's behaviour between the telehealth and face-to-face conditions, although variation between individuals was observed. Parents provided generally positive feedback about the use of telehealth for the assessments.

CONCLUSIONS & IMPLICATIONS

The findings of this study provide preliminary support the use of telehealth assessments of school-aged children with autism. Comparison of telehealth and face-to-face assessment scores showed high agreement and correlation, and while the children showed individual differences in their behaviour during the telehealth sessions, there was no clear difference between the conditions at the group level. The findings suggest that telehealth may present a reliable and feasible approach to the assessment of language for children with autism in some circumstances as a primary or adjunct service model, while acknowledging that individual differences among these children may be important to consider when planning both assessment and intervention via telehealth.

Telepractice for School-Based Speech and Language Services: A Workload Management Strategy

Purpose

This article discusses the combination of onsite and telepractice services as an effective way for professionals working in multiple schools to maximize their time and professional services in an effort to manage their workload. The combined onsite and telepractice services were used by district-wide school-based professionals to deliver direct and indirect services across various locations, thereby reducing time-consuming travel and increasing scheduling efficiency. The possible uses of telepractice as a workload management tool are discussed, as well as some challenges that the team overcame in order to successfully use this method.

Conclusions

Telepractice, in combination with onsite services, is an effective workload strategy for school-based therapists.

Telehealth and autism: A systematic search and review of the literature

PURPOSE

Research interest in telehealth and autism spectrum disorder (ASD) has grown. There is a need to review the literature to allow speech-language pathologists (SLPs) and other service providers to consider applicability to their settings. The aim of this review was to examine the nature and outcomes of studies examining telehealth assessment and/or intervention in ASD.

METHOD

A systematic search of the literature was undertaken, with 14 studies meeting inclusion criteria. The authors extracted information from each included article, including participant characteristics, technology used, measures and reported outcomes. Quality review of articles was undertaken.

RESULT

The 284 participants with ASD across the 14 included studies ranged in age from 19 months to adulthood. The quality of the studies varied. A range of services were provided via telehealth, including diagnostic assessments, early intervention and language therapy. Results suggested that services delivered via telehealth were equivalent to services delivered face to face, and superior to comparison groups without telehealth sessions.

CONCLUSION

The findings suggest there may be a range of benefits in using telehealth with individuals with ASD, their families, and teachers. Further research, however, is required particularly regarding the use of telehealth directly with children with ASD for assessment and intervention.

Comparing Traditional Service Delivery and Telepractice for Speech Sound Production Using a Functional Outcome Measure

PURPOSE

Using American Speech-Language-Hearing Association's (ASHA's) National Outcomes Measurement System (NOMS) Functional Communication Measure (FCM) as a common metric, this investigation compared traditional service delivery and telepractice service delivery for children receiving therapy for the NOMS diagnostic category of "speech sound production."

METHOD

De-identified cases were secured from ASHA's NOMS database and a proprietary database from a private e-learning provider. Cases were included if they met 3 criteria: (a) children received treatment exclusively for speech sound production, (b) they were between 6.0 and 9.5 years old, and (c) they received therapy lasting between 4 and 9 months. A total of 1,331 ASHA NOMS cases and 428 telepractice cases were included. The 2 groups were matched by initial FCM scores. Mann-Whitney U tests were completed to compare differences in the median change scores (the difference between the initial and final FCM scores) between the 2 groups.

RESULTS

There were no significant differences in the median change scores between the traditional group and the telepractice group.

CONCLUSIONS

These results suggest comparable treatment outcomes between traditional service delivery and telepractice for treatment of children exhibiting speech sound disorders. The findings provide support for the use of telepractice for school-age children.

Clinical Aspects Related to Tele-AAC: A Technical Report

Tele-AAC is a method of service delivery in which professionals provide intervention, assessment, and consultation services through the use of telecommunication technologies to individuals who use augmentative communication systems. In response to the nationwide shortage of highly trained speech-language pathologists, tele-AAC has emerged as a viable way to reach underserved clients. This paper examines the clinical aspects related to tele-AAC, including required and supplementary technology/equipment, resources and personnel needed, training, and quality assurance considerations. In addition, the infrastructure necessary to deliver the range of synchronous and asynchronous tele-AAC services is discussed.

Telepractice in the assessment and treatment of individuals with aphasia: a systematic review

Telepractice involves the application of technology to deliver services over a geographical distance. Studies in which telepractice procedures were used in the assessment or treatment of individuals with aphasia were reviewed. Systematic searches identified 10 studies meeting inclusion criteria. These studies were evaluated in terms of the: (a) characteristics of the participants, (b) technology utilized (c), services delivered via telepractice, (d) research methodology, and (e) results and conclusions of the study. Telepractice was used by speech-language pathologists and allied health professionals to assist with the delivery of services to participants with aphasia by their caretakers or clinicians. The services delivered included appraisal, diagnostic assessments, interventions, and consultation. This review suggests that telepractice is a viable method of service delivery for individuals with aphasia, however further research is warranted. Guidelines for practitioners and potential directions for future research are discussed.