In the first post of this series, Systems and Technology, I discussed what systems and technology must be considered and provided in order for speech-language services to be successfully delivered via teletherapy. Teletherapy doesn’t exist without the technology. However, typically the most pressing question of speech-language pathologists who are considering and researching teletherapy is, “What clients will or will not be appropriately served by this service delivery model?” 

Part 2: Client Considerations

The American Speech-Language-Hearing Association (ASHA) outlines four student-related factors to consider when determining a student’s appropriateness for teletherapy services: 

1. Physical and sensory characteristics  

2. Cognitive, behavioral, and/or motivational characteristics 

3. Communication characteristics  

4. Client’s support resources (e.g., technology, support personnel) 

Regardless of service delivery format, it is always the treating SLP’s role to conduct ongoing informal assessments of each student’s progress and the effectiveness of evidence-based practices, therapy environment, and duration and frequency of services. 

However, ASHA’s identified factors might suggest the following questions when providing services via teletherapy:

1. Physical and sensory characteristics: What is the student’s level of ability to physically access the computer and related tools?  

2. Cognitive, behavioral, and/or motivational characteristics: What is the student’s level of ability to attend to a computer screen for a full session?  

3. Communication characteristics: Is the student non-verbal, and/or does he/she utilize a low- or high-tech AAC system to facilitate communication?  

4. Client’s support resources: Does student have an appropriate level of on-site support to support participation in teletherapy sessions? 

While the factors outlined by ASHA highlight the primary student and environmental factors that can be potential challenges to the effective provision of speech-language services via teletherapy, it is crucial to also consider the following:

1. Determining the potential appropriateness and effectiveness of teletherapy as a service-delivery model is an ongoing, dynamic process. Assuming the appropriate technology is in place, a student’s disability, IEP goals, or severity of impairment should not be applied as automatic disqualifiers for inclusion in a telepractice model of therapy. As with in-person speech-language services, each student must be considered individually and without predetermination.  

2. It is important, as SLPs, to maintain professional perspective when addressing potential challenges to the telepractice service-delivery model. Specifically, consider if any identified factors might also be challenges, to some degree, even if the services were to be provided in-person. The scope of practice for SLPs is broad, therefore SLPs are continually adapting and expanding their skill sets as caseloads and practices develop. 

Given this framework, regardless of whether the teletherapist is being asked to make determinations about onsite vs. online services (assuming both service delivery models are an option), or it is known that all students will be receiving therapy online, it is essential to address any concerns or potential barriers to online services prior to the start of therapy.

To those new to teletherapy, a student’s physical and/or sensory characteristics are the most obvious potential barrier to effective online speech-language services—for good reason!

 For instance, it is clearly not appropriate for a student who cannot physically access a computer mouse to be brought to the computer for a teletherapy session without an adaptation or support in place that allows the student to engage in goal-directed activities with the teletherapist. 

And what about students with sensory issues that prevent them from wearing a headset? 

How do the teletherapist and site staff ensure appropriate audio during sessions?

IEP accommodations and Least Restrictive Environment (LRE): Don’t reinvent the wheel.

When working with schools and onsite staff regarding students who are being proposed for teletherapy services, the first discussion should be related to those adaptations and supports that are already in place for each student to meet the IEP requirements of Least Restrictive Environment (LRE). 

It is likely appropriate that classroom-based accommodations and supports also be provided during teletherapy sessions.

• How does each individual student currently interact with computers? For example, for a student with a hearing impairment, has the district audiologist provided an audio boot to allow for direct connection between the student’s hearing aid and the computer audio? Are visual overlays provided for students with visual impairments? Are any apps being utilized to integrate a student’s AAC device with the computer? Does the student use an adaptive computer mouse when participating in computer-based activities?  

• What environmental adaptations are implemented to support a student’s sensory issues? For instance, does the student’s IEP include accommodations such as a quiet work environment, or a visual room divider in order to complete assignments and testing? Does the student respond positively to a weighted vest when he/she becomes overstimulated or has difficulty focusing?  

• Is some level of paraprofessional/staff support needed for the student to participate in the general education environment? If the student receives 1:1 paraprofessional support throughout the school day, this level of support will likely also be required for the student to successfully participate in teletherapy. 

Onsite staff support for teletherapy sessions: Set the stage for success!

Beyond inclusion of any and all IEP accommodations that would also support a student’s participation in teletherapy sessions, it is crucial to establish reasonable expectations regarding the level of support that will be required from an onsite support person. 

This can be tricky because as we all know, staffing is typically tight in schools, so finding an “extra” person to support students participating in teletherapy is often a challenge. 

However, lack of the appropriate onsite support can also be the factor that limits or even prohibits a student’s success with this model. 

As I work with schools to implement teletherapy services, I explain the spectrum of needed support:

• Most students are able to participate independently! The majority of students only require line-of-sight supervision. They might need help logging on for each session, or might need an adult to work with the teletherapist to do some quick tech troubleshooting, but they are able to fully participate in each therapy session independently.  

• Some students are able to independently engage with the teletherapy platform, but might need a support person in the room and available to work with the teletherapist to implement attention or behavior supports. I am often asked about how teletherapists manage student attention or behavior issues if not physically in the room. This concern is understandable. Some students who exhibit mild to moderate attention and behavior needs in the classroom are highly motivated by computer-based activities, so it’s not uncommon to see a natural increase in attention and decrease in distracted behaviors during teletherapy sessions. However, if attention and behavior issues persist, the teletherapist needs to be able to collaborate with the onsite support person to ensure the most efficient and effective use of therapy minutes. For instance, a student might need a quick physical break every 5 minutes in order to maintain focus during therapy. The support person can work with the teletherapist to come up with quick physical activities (e.g., jumping jacks, crossing midline activities) that will support the student’s focus but not be a disruption to any other students who might be in the room. Or, while many students are motivated by the reinforcements available in the teletherapy room, such as quick videos or games, others might need snacks or stickers for motivation. The onsite support person can facilitate these physical motivators.  

• 1:1 support is sometimes required. A good place to start when determining the level of onsite support required is to ask about the staff supports needed for each student to participate in the general education setting. If 1:1 (or if the student is supported in a moderate-to-severe needs setting) then 1:1 support will probably be required in order for the student to successfully participate in teletherapy sessions. For instance, a student who is non-verbal, uses an AAC device, and cannot physically access a computer mouse will need an onsite support person (ideally the student’s 1:1 paraprofessional) throughout each session. The support person would wear a headset during the session (or computer audio if appropriate) so the teletherapist can be in continual communication. The teletherapist might coach the support person related to the AAC device, if tactile cueing is needed, or if any other items from the student’s environment need to be included in the therapy session. 

SLPs are trained to select and adapt activities that most appropriately support each student’s progress on each IEP goal, and providing services online is no exception!

One of the biggest surprises to me when I first made the transition from onsite services to teletherapy was how similar my therapy sessions were. 

All my training and experience in working with students and developing motivating and goal-directed activities applied directly to my work as a teletherapist, and thanks to the incredible activity library available in the PresenceLearning platform, I was also able to explore activities developed by hundreds of other SLPs!

Before starting therapy I reviewed my student’s IEPs including accommodations and goals, grouped students as appropriate, selected activities I thought would be motivating, and built the activities around goals and tracked data accordingly. 

If the activities I selected did not seem to be motivating my students or appropriately supporting progress on goals, I would explore and implement other activities.

Sound familiar? 

My overall process as a teletherapist was identical to what it had been as an onsite SLP! 

The primary difference was that instead of having to make photocopies before sessions and cart bulky games and activity boxes from site to site, all my materials were online and available immediately.

It is also important to note that teletherapy should not be limited to online activities. 

There are certainly circumstances under which it is best practice to include objects and materials from the student’s environment. 

For instance, it is developmentally appropriate when working with preschool-age students to have favored objects/toys available next to the computer. 

The student can hold and play with the physical objects, and the teletherapist can integrate them into the therapy session. 

The teletherapist should not feel limited to what is available in the therapy platform, but should feel free to adapt and be creative as appropriate for each student’s developmental and ability levels.

Establishing best practice for teletherapy client consideration is a process, and not something that can be done by looking at a list of students categorized by primary disability. 

It requires the clinical knowledge and experience of the treating SLP, as well as strong communication between the SLP and each school site.

 I look forward to any comments and feedback, as well as covering the next topic in this series: "Brick-and-Mortar vs. Virtual School Students"