Since we receive a lot of questions about how telepractice can help people with various impairments such as Selective Mutism, Stuttering, Dysphagia, Pragmatics, and Articulation tactile cues, we thought we’d have Nate Cornish, M.S., CCC-SLP, answer from the perspective of a practicing speech pathologist:
Although ASHA has embraced telepractice as an “appropriate model of service delivery for the professions,” (ASHA, 2005a), the Association has also stated that “the quality of services delivered via telepractice must be consistent with the quality of services delivered face-to-face.” Like every clinician, a good telepractioner must examine the efficacy of her or his techniques.
I think it’s important to note that one aspect of “Evidence-Based Practice” is “Practice-Based Evidence.” Many studies that show support for the efficacy of telepractice. This is very promising. However, telepractice is a new use of technology. In our professions formal research often follows and may even be inspired by competent clinicians who have used their knowledge of specific conditions and systematically explored available methods to address them. This has been the process within various areas of our professions. For example, to date there is a very limited number of studies published in the ASHA journals on the effectiveness and/or methodology of bilingual intervention. However, clinicians provide effective services in more than one language every day.
So what is our professional responsibility to provide Evidence-Based Practice (EBP) when there is limited information in the literature on our methods? Justice and Fey (2004) remind us of the following, “EBP does not refer to a singular focus on using research to make decisions about children. Rather, EBP emphasizes the systematic and deliberate integration of science and craft, or, alternatively, data and theory.” We learn everything we can about an impairment, how it may interact with a given treatment method, and we develop a plan for competently using that method with a specific client. We also systematically take data, evaluate our methods, and revise our methodology as needed.
That said, treatment and carryover in addressing the situations mentioned above will probably look very different for each child. However, I’d like to share the process that a telepractioner might use as he or she begins to make clinical decisions. I’ll address Selective Mutism (SM), although I think working with a Fluency or Pragmatic student might involve similar elements. This process includes reviewing (and perhaps increasing) background knowledge, recognizing limitations, potential advantages, needs, and determining first steps.
- Background Knowledge: We know that SM is a spectrum that involves complicated social and communication needs. Treatment will likely encourage the child to move through various stages of increasing interaction and sound production. It will also require support from other team members to address any underlying social situations.
- Limitations: It may be difficult to obtain authentic information about what the child is doing outside the session room. There may also be challenges in coordinating the interactions between multiple individuals and environments.
- Potential Advantages: The child may respond to the small 1:1 ratio offered in a telepractice setting. The distance of the remote clinician may also be perceived as “safe” by the child and could permit greater communication.
- Needs: I am going to need some allies and close communication with various team members at the school and at home.
- First Steps: Establish a system of regular contact with the family, the classroom teacher, the social worker, etc. That may be by telephone or e-mail; it is my responsibility to be flexible. I should educate all team members on SM and discuss the plan of treatment. It is my job to train adults on what to look for and how to respond to the child. I should educate myself about the strategies they are already using- what has worked and what hasn’t? We will also develop a systematic way of reporting observations. During sessions, I may start off with some simple, non-verbal turn-taking activities, (easy to do via telepractice). I will also give other adults similar activities they can do in the classroom and at home. With each success I can move up to increasingly complex interactions and eventually sound production activities. All along I am collaborating with people on-site, taking good data and revising any steps that aren’t working.
In regards to dysphagia and the use of tactile cues in articulation therapy, this raises a great series of questions. The initial question I see here is, “How does a telepractitioner manage the need for tactile and physical manipulation?” I think we can follow that a little further with, “Is teletherapy appropriate for all situations?”
Tactile and physical manipulation is something a telepractioner needs to approach very carefully and creatively. ASHA addresses this in the following manner, “Physical contact with a client is used by clinicians for cueing, reinforcement, tactile manipulation, and stimulation, and to assess strength and tone. In the telepractice environment, this must be provided in alternative ways, such as training a family member or paraprofessional at the remote site, or using visual/verbal means.” (ASHA, 2005b). When appropriate, we can train others to provide some of this physical contact for us. In the case where physical contact has the potential to compromise the health and safety of a client, the telepractitioner may collaborate with professionals who possess more specialized knowledge and skills such as nurses, occupational and physical therapists.
Even when we maximize the trained and untrained resources that are available on-site, there may still be some aspects of a therapeutic interaction that cannot be safely or effectively delegated to someone who is not a speech-language pathologist. I believe that telepractice is not a viable answer for every need a client may potentially present with, and that it is the ethical responsibility of clinicians and team members to identify when that is the case. It is important to remember that this is a dynamic that is not unique to telepractice. Clinicians routinely refrain from engaging in activities that are within the profession’s scope of practice, but outside their personal experience or skill set. Patients are commonly referred to specialists or transferred to facilities that can meet their unique needs. Children change to school programs that can address their educational goals in the least restrictive environment. It would not be unprecedented, and is actually expected, that at some point a telepractitioner should say that a client’s particular needs cannot be met through telepractice. However, not engaging in telepractice, or even employing it as a last resort, may deprive clients of much-needed services that wouldn’t be available to them otherwise.
There is much more for us to understand about the benefits, limitations, effectiveness and best uses of telepractice. That is also true for every other aspect of our professions. Clinical decisions in telepractice- and all areas of our professions- must be guided by strong background knowledge, recognition of potential limitations and advantages, educated theory, and good data. As we do this I’m sure we will become more skilled a making telepractice a powerful and versatile tool in addressing client needs.
American Speech-Language-Hearing Association. (2005). Speech-language pathologists providing clinical services via telepractice: position statement [Position Statement]. Available from www.asha.org/policy.
American Speech-Language-Hearing Association. (2005). Speech-language pathologists providing clinical services via telepractice: technical report [Technical Report]. Available from www.asha.org/policy.
Justice, L. M. & Fey, M. E. (2004, September 21). Evidence-Based Practice in Schools : Integrating Craft and Theory with Science and Data. The ASHA Leader.