Teletherapy – 4 Years Later

Written by Sarah Van Dusen
July 20th, 2015

In October of 2011, I posted about my new trek into teletherapy. I was full of anxiety about whether or not it could truly be effective with my students who have apraxia, but as I got going, I realized that teletherapy has its own advantages among the more obvious disadvantages. This is my update after significantly more experience in the realm of teletherapy. (If you haven't read the original post, you can see it here.) Enjoy several examples of teletherapy with apraxia and some of the lessons I have learned along the way.

The young man I wrote about in the previous post ended up doing very well and completing his therapy within the year. His speech and language were on par with his peers, and we were all very happy with the results. However, I still wasn't sure long distance therapy was going to be the answer for many students with apraxia. Perhaps it worked with this guy because I had seen him for months in my office before our online sessions, he was a much older kid (twelve years old), his parents were heavily involved, and he was intrinsically motivated. Even with these concerns, I got suckered into trying this again.

My next online only client was an eleven year old girl whose family had attended our Walk for Apraxia in Dallas. They had driven a long way to attend, and we agreed that she needed more specialized therapy than she was able to receive in her rural community. So, she came to my office for an evaluation and continued to come weekly for therapy, but the burden of five hours on the road for speech was too much when school started. On the pros list for this child, in addition to her age, intrinsic motivation, and previous experience in my office, was that she had a school therapist and reading teacher who were eager to participate in her therapy and learn more about treating children with apraxia. Every week, the four of us (and sometimes, mom when she was available to come to the school) got together online to practice speech, get some training, and adapt her schoolwork to meet her needs. This was a beautiful example of team treatment. After the first year, we were able to drop to once a month, because the therapists on her end had been trained well enough to meet her needs without the help of a specialist.

Another online client was a student I had seen in person for over a year. Her family moved out of the country, and while they tried very hard to find quality apraxia therapy in their new area for the first several months, they eventually realized it wasn't enough. The mom and I discussed trying a little teletherapy, so I could guide her on the best ways for her to carry out the speech therapy at home. It quickly turned into weekly, online sessions. My concerns about working with this girl compared to my previous online clients were that she was only five years old, I hadn't seen her in more than a year, and at that time, her apraxia was quite severe and accompanied by significant frustration. One item in the pros column was that I knew parental involvement was not going to be a problem. These were dedicated parents who were used to my methods and practicing speech at home.

Overall, this therapy worked for my young friend. She made progress, but not at the rate I believe she would have made if we were working in person. I planned her therapy and sent my plans to her mother for adaptation according to the toys and materials they had available. I also created 2 dimensional materials and put them in Dropbox, so that her mother could print them and prepare them for therapy. We talked regularly about how the progress was coming at home and how to adapt the therapy. Our biggest hangup was that I couldn't get in her mouth. For example, when we were working on proper tongue placement for her alveolars (/t,d,n,s,z,l/), I was using every description I knew to use, and mom was using every description she knew to use to make up for the limitations created by video conferencing. It still wasn't enough. So, I told mom she needed to see an SLP in her area to help me understand exactly what was happening and determine if the placement was exact. Luckily, this family had a neighbor who was trained as an SLP but wasn't practicing. She was kind enough to look in the girl's mouth and assure us that she was getting the placement correct. This is a common hurdle in teletherapy and was cause for further concern about wasting a family's time or money.

This particular family ended up moving back to the Dallas area, and we are finishing up the therapy now in person. I have definitely found it easier to work with her in person, but I know that the time spent online forced me to be a better parent trainer, and it was much better than the alternative which was no therapy at all.

Another teletherapy case was with a spunky, five year old in another state. I met her mom and grandmother at a CASANA Conference. This American family lived outside the U. S. when they realized their daughter had a speech problem that was more than just a delay. They moved back to the states to get the help she needed, but they kept meeting dead ends in therapy. Why wasn't she getting it? The mother attended one of my sessions at the conference regarding the differences between traditional speech therapy and apraxia-specific therapy. She knew that her daughter was receiving the former in their rural town, and that was not going to get the job done.

Again, I was asked to do teletherapy. Again, I was nervous about it. I had never met this child, so I told the parents I would do it on a trial basis, but they had to come to Dallas for the evaluation. They packed up their minivan and three kids and made their way over 750 miles to Dallas for a few weeks. In that time, I evaluated the little girl, provided therapy every day, began parent training, and determined what the difficulties were going to be for teletherapy. This girl's apraxia was severe. She had no intelligible speech. Now, I've done it, I thought. I've bitten off more than I can chew. By the end of their stay, I was certain I knew where to start, and all we could do was try.

In this case, mom took pictures of their toys. She sent them to me, and I planned my therapy around the toys they had in their house and again, sent 2D materials via email or snail mail when necessary. This mother was an educator and creativity was her gig. She was able to help me use the materials available. Again, heavy parent training was involved. I would have loved to have the support of her public school therapists, but they were not interested in working with me, so mom became the educator for them and the quintessential advocate for her child.

Again, one of the greatest challenges was that I could not get into her mouth, so mom and I did the best we could to explain to one another what was happening and how to try something different. It paid off. She made mountains of progress, and we continued in this vein until a therapist moved near them who was quite qualified to take over the therapy in person.

I continue to see some online clients, and this has opened me to being able to see current, in office students via the internet when we have any freezing precipitation in Dallas (which means shutting down the entire city), when a sibling is ill, when a car is in the shop, etc. Now, my students don't have to miss therapy when life gets in the way.

I have learned many lessons along this journey.

  1. I have learned to stretch my idea of who is a good candidate for teletherapy. I continue to look at age, physical abilities (vision, hearing, etc.), cognitive abilities, attention, motivation level, severity of impairment, environment, technology, and the facilitator (among other things) when determining good candidates for teletherapy, but I have also learned that many of these problems can be addressed by teaching the child and facilitator how to participate in teletherapy. For me, every teletherapy client begins on a trial basis. I will not continue doing long distance therapy if I determine they can receive more effective treatment another way. (This is no different than my clinic. I will not provide therapy for a child in my clinic if I determine that child can receive more effective therapy from another provider.)
  2. Parents and local SLPs are my greatest allies in teletherapy! With proper training from the apraxia specialist, advanced planning, and regular communication, we can make a difference as a team.
  3. I learned that the therapist must be licensed in both the state from which she is providing the therapy and the state/country in which the therapy will be received. For more information about individual state laws and regulations regarding teletherapy, go to ASHA's website here.
  4. I learned that Skype is NOT HIPAA compliant! (Oops. I had to remedy that right away!) Google hangouts are not HIPAA compliant. I spoke to a representative at GoToMeeting who said that they are not HIPAA compliant either, although they appear to be working in that direction. Many of these platforms have HIPAA compliant encryption for data in use but not for data at rest, and many of them do not offer Business Associate Agreements. For a list of teletherapy services that do claim HIPAA compliance, check out TeleMental Health Institutes' list here. Not included in that list is iCouch. I am not endorsing any of these products, but I do want you to know some products that are available.
  5. Finally, health insurance is trending toward paying for teletherapy, but not all companies do that. Be sure to verify insurance coverage for teletherapy before entering into an agreement with your client or therapist.

For more information about teletherapy, review ASHA's website here. There is a video on my YouTube channel regarding this topic. Please visit Progressive Speech Therapy on YouTube to ask questions and discuss your experiences with teletherapy.

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