Telepractice A Clinical Guide for Speech-Language Pathologists (Melissa Jakubowitz, Lesley Edwards-Gaither) (z-lib.org)

TELEPRACTICE

A Clinical Guide for Speech-Language Pathologists



TELEPRACTICE

A Clinical Guide for Speech-Language Pathologists

Melissa D. Jakubowitz, MA, CCC-SLP, BCS-CL, F-ASHA
Lesley Edwards-Gaither, PhD, CCC-SLP

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Library of Congress Cataloging-in-Publication Data:
Names: Jakubowitz, Melissa, author. | Edwards-Gaither, Lesley, author.
Title: Telepractice : a clinical guide for speech-language pathologists /

Melissa Jakubowitz, Lesley Edwards-Gaither.
Description: San Diego, CA : Plural, [2022] | Includes bibliographical

references and index.
Identifiers: LCCN 2021055626 (print) | LCCN 2021055627 (ebook) | ISBN

9781635503807 (paperback) | ISBN 1635503809 (paperback) | ISBN
9781635503791 (ebook)
Subjects: MESH: Speech Disorders--therapy | Language Disorders--therapy
Speech-Language Pathology--methods | Telemedicine--methods
Classification: LCC RC428 (print) | LCC RC428 (ebook) | NLM WL 340.2
DDC 616.85/506--dc23/eng/20220111
LC record available at https://lccn.loc.gov/2021055626
LC ebook record available at https://lccn.loc.gov/2021055627

Contents

Preface ix
Acknowledgments xi
Reviewers xiii

1 An Introduction to Telepractice 1
Telepractice Past and Present 1
History of Telepractice 2
Telepractice Terminology 6
Pandemic and Health-Emergency Implications 8
Resources 9
Resuming In-Person Services 10
Summary 11
References 13

2 Technology 15
Internet Speeds 15
Computer Specifications 16
Headsets 18
Cameras 19
Videoconferencing Platforms 20
Service Delivery Models 22
Face-to-Face 23
Blended Learning 23
Hybrid 24
Hybrid Versus Blended Learning 25
Telepractice 25
Determining the Service Delivery Model That Best 26
Suits the Client
Addressing Absenteeism 27
Future Directions 27
Strategies to Improve Telepractice Models 28

v

vi  Telepractice:  A Clinical Guide for Speech-Language Pathologists

Future Directions in Telehealth 28
Artificial Intelligence 29
Speech Recognition 31
Ten Tips to Make Connections Using Technology 33
References 35

3 Models of Service Delivery 37
Introduction 37
A Review of Literature and Telepractice Research 38
Client Candidacy 42
Apps and Websites 49
Cultural and Linguistic Considerations for Teletherapy 55
Culture and Technology 57
Preference for Digital Communication 58
Technology to Address Linguistic Considerations 59
References 60

4 Assessments, Evaluations, and eHelpers 67
Introduction 67
Research and Evidence-Based Practice 71
Collaboration 77
Managing Technology 78
Parent Coaching 79
Training 81
Assessments and Evaluations 82
Setup for Successful Administration of Assessments 84
Standardized Assessment 87
Modifications 94
Report Writing 94
References 96

5 Engaging Clients:  Case Scenarios 101
Introduction 101
Case Scenario:  Early Intervention 102
Background Information 102
Goals and Objectives 103
Telepractice Applications 103

Contents  vii

Therapy and Materials 105
Challenges and Lessons Learned 105
Case Scenario:  Preschool Telepractice 106
Background Information 106
Telepractice Applications 107
Critical Thinking Questions 108
Case Scenario:  Culturally and Linguistically Diverse Clients 109
Background Information 109
Telepractice Applications 110
Critical Thinking Questions 111
Case Scenario:  Elementary 111
Background Information 111
Telepractice Applications 111
Critical Thinking Questions 113
K–12 Case Scenario:  Language Intervention 113
Background Information 113
Telepractice Applications 114
Critical Thinking Questions 115
Case Scenario:  Middle School 115
Background Information 115
Goals and Objectives 117
Telepractice Applications 117
Therapy and Materials 118
Challenges and Lessons Learned 118
Case Scenario:  High School 119
Background Information 119
Goals and Objectives 121
Telepractice Applications 121
Therapy Materials 122
Challenges and Lessons Learned 122
Case Scenario:  Adult 123
Background Information 123
Goals and Objectives 124
Telepractice Applications 124
Therapy Materials 125
Challenges and Lessons Learned 127
References 127

viii  Telepractice:  A Clinical Guide for Speech-Language Pathologists

6 Telepractice as a Business 131
Introduction 131
The Business Plan 133
Setting Therapy Rates 137
Marketing for Private Clients 140
Marketing to Schools 142
Setting Up for Success 148
Safety of Clients 156
References 157

7 Confidentiality, Ethics, and Legal/Regulatory Issues 159

in Telepractice
Introduction 159
Code of Ethics 160
State Regulations 162
Licensure Compacts 163
The ASLP-IC 164
Telepractice and Licensure Compacts 164
Telepractice Opportunities Related to the ASLP-IC 165
Federal Legal and Regulatory Issues 166
References 171

Index 173

Preface

March 2020 changed many lives with the pandemic in full swing
and the shutdown of the economy to mitigate the spread of the
virus. SLPs’ jobs were disrupted no matter the setting. Many moved
very quickly, providing services via telepractice or utilizing masks and
PPE to continue providing services to their clients. For those SLPs
utilizing telepractice, it was a very steep learning curve. They had to
figure out how to use the platform that employers told them to use,
whether appropriate or not for their population. It was a scramble
to figure out how to use an unfamiliar platform, finding materials
that worked online, and adjusting schedules. At times, this situation
seemed untenable, but due to the resilience, tenacity, and determina-
tion, many clinicians found the joys of telepractice.

We wrote this book to support our colleagues in providing
evidence-based, high-quality telepractice services. This book was
developed with the pandemic in mind; however, telepractice has
grown since the mid-2000s. In recent years (before the pandemic),
SLPs have been adopting telepractice as a service delivery model in
increasing numbers.

Although references to the pandemic and COVID-19 are present
throughout the book, the work goes well beyond the pandemic. It
describes telepractice, which was utilized before the pandemic and
will continue to grow, following the resolution of the pandemic.

ix



Acknowledgments

Ithank the many people who encouraged me to bring this project
to fruition. First, my husband Julian, sons Jonathan, Joshua, and
Gabriel were understanding and patient from the first day to the last.
I am grateful for their love and daily dose of humor. I would also
like to thank my George Washington University students for their
insight which inspires me daily. Finally, I acknowledge and thank
the students and families that have allowed me to enter their homes
through countless videoconferencing sessions over the past decade.
While some of us will never meet in person, you have become a part
of my own home and the fabric of my career. It is a privilege to be a
part of your journey. I will never stop learning new things that make
me more humble, knowledgeable, and, I hope, a better human being.

Lesley Edwards-Gaither

Iacknowledge and thank my co-author, Lesley, for agreeing to write
this book with me. I am grateful for her insights, thoughtfulness,
and partnership in getting this book to the finish line. I couldn’t have
done it without her. In addition, I thank my family: my husband,
Larry, and my children, Lia and Adam, for their unending support
and encouraging words as I made my way through the writing process.
Finally, I want to acknowledge my friends and colleagues who sup-
ported me before and during the writing process for their encourage-
ment and support. Also, Monica and Mike for being my cheerleaders,
answering questions, and just being there for me. Without the support
of all these individuals, this book would not have been possible.

Melissa Jakubowitz

xi



Reviewers

Plural Publishing and the authors thank the following reviewers for
taking the time to provide their valuable feedback during the man-
uscript development process. Additional anonymous feedback was
provided by other expert reviewers.
Robin L. Alvares, PhD, CCC-SLP
Clinical Assistant Professor
Master’s Program in Speech-Language Pathology
Caruso Department of Otolaryngology-Head and Neck Surgery
University of Southern California
Los Angeles, California
Amber Heape, ClinScD, CCC-SLP, FNAP, CDP, CMDCP
Clinical Specialist
Pruitthealth Therapy Services
Branchville, South Carolina
Denise A. Ludwig, PhD, CCC-SLP, FNAP, ACUE
Professor
Grand Valley State University
Allendale Charter Township, Michigan
Joan MacIsaac, MA, CCC-SLP
Project Director
Round Hill, Virginia
Jyutika Mehta, PhD, CCC-SLP
Professor
Department of Communication Sciences and Oral Health
Texas Woman’s University
Denton, Texas

xiii

xiv  Telepractice:  A Clinical Guide for Speech-Language Pathologists

Rachel Pittmann, MS, CCC-SLP, MEd
Director
Impact Practice Center
MGH Institute of Health Professions
Boston, Massachusetts
Janet Rabinowitz, MS, CCC-SLP
Adjunct Clinical Supervisor
University of Redlands
Redlands, California
Tara Roehl, MS, CCC-SLP
Speech-Language Pathologist
Speechy Keen SLP
Firestone, Colorado
William Eric Strong, PhD, CCC-SLP
Assistant Professor
Department of Speech, Hearing, and Rehabilitation Services
Minnesota State University, Mankato
Mankato, Minnesota
Samantha Washington, EdD, CCC-SLP
Assistant Professor
Southeast Missouri State University
Cape Girardeau, Missouri
Sarah Zsak, MA, CCC-SLP
Owner and Lead Therapist
Terrapin Speech Institute
Anne Arundel County, Maryland

1 An Introduction
to Telepractice

Telepractice Past and Present

Although telepractice has existed for at least 20 years, it was not
widely used until the global health emergency, COVID-19 pan-
demic. During that time, all settings—from hospitals, outpatient facil-
ities, schools, and academic clinical settings—evaluated their current
use and future need for telepractice services and competency. At that
time, most schools, private practices, and hospitals quickly turned to
telepractice to meet the needs of clients and students with Individ-
ual Education Plans (IEPs), as well as adult clients in need of direct
speech-language pathology services. The utilization of telepractice
went from below 5% among speech-language pathologists (SLPs) to
well over 80% (ASHA, 2021a) in a brief period of time.

Many clinicians transitioned to telepractice quickly, with
little-​to-no training, as schools, private practices, and hospitals
were scrambling to figure out how to continue to provide services
to their clients or students. Many hospitals continued in-person
services as personal protection equipment (PPE) was more readily
available for SLPs. However, few school districts considered the
impact of online learning for general education or special educa-
tion students, and how this would look. In addition, they had little
knowledge of telepractice or how it could potentially assist them in
providing Free and Appropriate Public Education (FAPE). Private

1

2  Telepractice:  A Clinical Guide for Speech-Language Pathologists

practitioners, on the other hand, knew they needed to move quickly
to preserve their practices. Once it became apparent that the nation
was in for the long haul with online services, some districts began
to take a closer look at what was needed to provide appropriate
online services. At the same time, private practices were more deft
in obtaining training and moving forward quickly with telepractice
services for their clients. Hospitals were also able to move toward
teletherapy services in order to meet the needs of outpatient clients.

History of Telepractice
Speech-language pathologists have been providing teletherapy ser-
vices for some time now. The history of providing services via tele-
communications technology goes back to the advent of the telephone
in 1876. In the 1880s, physicians began experimenting with telecom-
munication technologies. The Department of Veterans Affairs (VA)
first recorded the use of telemedicine in 1957 (Kumar & Cohn, 2013).
It was utilized for a telemental health project in the state of Nebraska.
Over the next 20 years, the VA developed other telemedicine projects
that led to the adoption of a shared telemedicine program throughout
VA hospital system. Since then, the VA has been a leader in develop-
ing telepractice (and telemedicine) services and research in this area.

Although there is some controversy about what constitutes the
dawn of telecommunications, suffice it to say modern telecommuni-
cation systems most likely began with the advent of the telegraph and
Morse code in 1844. The dawn of the telegraph allowed information
to be sent immediately to sites that were some distance apart. The use
of the telegraph spread quickly and was used to transmit messages
across the United States and elsewhere, contributing to the expansion
of the United States territories, among other things (Houston, 2014).

In 1875 Alexander Graham Bell voiced the now-famous words,
“Mr. Watson, come here, I want you!” (Houston, 2014). With that
statement, a new form of communication was born—the telephone.
A. G. Bell’s development of the telephone was based on his work with
children who were deaf and his belief that they could develop intel-

1.  An Introduction to Telepractice  3

ligible spoken language if given appropriate instruction (Houston,
2014). From the emergence and spread of the use of the telephone,
more technology evolved, including radio transmission. Following
radio was television and space exploration, which leads us to the
1990s and the expansion of the internet. As the use of the internet
grew along with computer technology during the 1990s, we saw one
of the first uses of videoconferencing technology, and that was Skype.
Skype technology was very glitchy in those early days, with audio
and video delays, calls dropping during use, and individuals hacking
into calls.

Since the advent of Skype, videoconferencing technology has
grown and improved significantly. At the time of this writing, most
videoconferencing technology is quite good, with minimal delays
between the audio and video feeds, allowing SLPs to provide ser-
vices via telepractice that is equivalent to in-person services. There
are currently several platforms that have been built specifically for
SLPs. Beyond the videoconferencing technology, these platforms may
include scheduling tools, materials, billing software, and so forth. This
technology continues to change and improve, assisting SLPs in doing
their job more efficiently and effectively.

As noted previously, the boom in technology has contributed
to the use of telepractice in the field of speech-language pathology.
Research in telepractice has also seen growth. In 2010, there were
approximately 40 articles in SLP-specific journals on telepractice;
currently, there are well over 150 articles that support the use of
telepractice as a service delivery model. Because telepractice is a
relatively new service delivery model, the research is still somewhat
limited but certainly assists in providing evidence-based services. The
focus of much of the research is on SLP services (Coufal et al., 2018;
Short et al., 2016; Zahir et al., 2021) in general, with limited articles
focused on specific disorders or techniques that work specifically for
telepractice. Much of the information gleaned provides solid support
for telepractice in general; there is still a need for research in specific
disorders and whether or not the evidence used in in-person settings
translates to a telepractice service delivery model (Cason & Cohn,
2014; Theodoris, 2011). The research needs to be expanded to larger
client populations.

4  Telepractice:  A Clinical Guide for Speech-Language Pathologists

Wiedner and Lowman (2020) conducted a systematic review
to examine the evidence for feasibility and efficacy of SLP services-​
treatment and assessments via telepractice for the adult population.
The authors focused on recent research between 2014 and 2019. The
authors initially identified 125 articles for their review, with a total of
31 meeting their criteria for inclusion in the qualitative analysis. The
authors also collected and presented information regarding equip-
ment used for telepractice and pinpointed the setting in which the
service was provided.

These authors (Weidner & Lowman, 2020) concluded that
telepractice was feasible and showed preliminary efficacy for using
telepractice as a service delivery model. Approximately half of the
studies focused on individuals with aphasia at least six months post-
stroke. Other articles covered included Parkinson’s, primary progres-
sive aphasia, TBI, voice, and mixed populations. As telepractice is a
developing service delivery model, there are opportunities for further
research. The authors noted limited information in their search on
providing telepractice for adults with motor speech disorders, aug-
mentative and alternative communication, and dementia. Overall,
there were positive outcomes in this systematic review.

One area noted for further research (Weidner & Lowman, 2020)
was the use of facilitators in the telepractice service delivery model.
There was little-to-no research regarding the use of facilitators with
adults. Although there appears to be some research about facilitators
in pediatric and school settings, using them with adults is an area ripe
for research.

In 2012, Tindall reviewed the previous research in the use of
telepractice with adults with various diagnoses. Tindall noted that
prior to 2012, when technology was somewhat limited, compared to
today, researchers were finding telepractice appeared to be effective
in treating and diagnosing speech and language disorders in adults.
It was mentioned that the results, at that time, were promising, but
further investigation was needed. Telepractice appeared to enable
some clients who might otherwise not receive services to partici-
pate in treatment. Empowering older adults and their families to
participate in their care helped to relieve the stress associated with
caregiver burden.

1.  An Introduction to Telepractice  5

Burns and Wall (2017) reviewed the use of telepractice with
Head and Neck Cancer (HNC) clients. They found that the adop-
tion of telepractice with these clients was slow, in part, due to limited
descriptions for implementation, even as telepractice was continuing
to grow. There were specific components that should be considered
in order to provide efficacy and quality of care to the client. These
components included “understanding current research, choosing
appropriate technology, client factors including suitability, adequate
training and evaluating the program regularly” (Burns & Wall, 2017,
p. 140).

Implementing an effective telepractice program for HNC clients
takes a team approach and the establishment of specific protocols
for successful implementation. Client factors and training are an
important part of setting up a plan to ensure that client and clinician
have skills necessary for receiving and providing teletherapy services.
Burns and Wall (2017) concluded that telepractice is a viable option
for the provision of speech and language services for clients with
HNC, and should have a good implementation plan in place that
includes all stakeholders in the process.

In another systematic review, Malandraki et al. (2021) com-
pleted a rapid systemized review of the literature published between
January 2020 and August 2020 to develop and guide clinical practice
for telepractice in dysphagia across the lifespan. None of the articles
on dysphagia in telepractice included pediatric clients. The most
common procedure mentioned in telehealth was the clinical swallow-
ing assessment, with therapy second to that. Telehealth was character-
ized as a “2nd-tier service delivery option” (Malandraki et al., 2021).
The authors concluded that during the pandemic, there were limited
articles published on the use of telepractice in dysphagia treatment
and assessment because of the view that telepractice was 2nd tier.

The authors (Malandraki et al., 2021) proposed a view of tele-
health as a 2nd-tier option that was similar to the sentiment expressed
by clinicians during their webinars. It was proposed that in order to
enhance current evidence by evaluating prepandemic research and
combining it with the reviewed articles along with their expertise in
the area, they establish a road map to guide clinicians in their clinical
decision-making. As reported in other articles (Burns & Wall, 2017;

6  Telepractice:  A Clinical Guide for Speech-Language Pathologists

Tindall, 2012; Weidner & Lowman, 2020), it is important to consider
legal ramifications, privacy, client safety, technology and client candi-
dacy that are laid out for clinicians to utilize in their decision-making
process for use of telehealth with dysphagia patients. Limitations and
the need for further research are noted.

Telepractice is here to stay, although it may decrease once the
pandemic has passed, it will most likely be utilized at a higher level
than prepandemic. It has been introduced in most school districts,
private practices, and many hospitals. SLPs are much more familiar
with it, and resistance has decreased considerably as more clinicians
become aware of the convenience and use of this service delivery
model. With that being said, it is time to ensure that SLPs are employ-
ing Evidence-Based Practice (EBP) and proven techniques and
materials. Ushering in this new era of telepractice post-pandemic is
exciting and exhilarating and brings a sense of responsibility for SLPs
to engage in ethical, responsible practice in teletherapy.

Telepractice Terminology
Many terms have been used to describe providing services utiliz-
ing telecommunication technology. In this section, those terms are
defined, as well as when they are typically used. These terms have
evolved over time as the use of telecommunications technology has
improved and increased.

Telehealth is often used as an overarching term in the medical
field to cover all aspects of providing services via telecommu-
nications technology. According to the American Telemedicine
Association (ATA, 2014, pp. 5–6), “telehealth is often used to
encompass a broader definition of remote healthcare that does
not always involve clinical services.”
Telemedicine, according to the ATA (2014, pp. 5–6), “is the use
of medical information exchanged from one site to another via
electronic communications to improve patients’ health status.
It encompasses the medical use of electronic communications.

1.  An Introduction to Telepractice  7

This goes beyond the use of videoconferencing technology
and may include various other electronic communication
devices such as the telephone, fax machines, remote moni-
toring, among others.”
Telepractice, is the term that ASHA has embraced to describe
what speech-language pathologists and audiologists do when
providing services online using videoconferencing technology.
This term was chosen because professionals in this field work
in many different settings (including medical, private practice
schools, clinics, homes, etc.) concluded that terminology was
needed that would encompass all professionals settings where
SLPs and Audiologists work.
Telespeech, teleaudiology, tele-AAC, and so forth, are terms
that are used to specify specific aspects of the services being
used.
Facilitator, eHelper are terms that refer to an individual who
works on the client-side, assisting the client in logging on,
troubleshooting, acting as the onsite eyes and ears of the clini-
cian. In this book, we will use the term facilitator throughout
to signify the individual who assists the clients at the computer,
as well as at the site of service.
The term Student is typically used when referring to the clients
that SLPs serve in school settings.
The term Patient is typically used in medical settings to refer
to a client who is being seen in a medical setting, as well as
occasionally in clinics and private practices.
In this book, we will use the term Client to refer to all individ-
uals that SLPs work with no matter the setting. It is a term that
is neutral when referring to the individuals SLPs work with and
does not connote a specific setting.
Telecommunications refers to the technology used in
a telepractice setting. It includes technology that allows

8  Telepractice:  A Clinical Guide for Speech-Language Pathologists

communication via an application or a website. It includes
videoconferencing technology, telephones, and so forth.
Remote services, online services are terms that refer to
providing services at a distance. The provider and the client are
not in the same room or building, and they may not even be in
the same state.

Pandemic and Health-Emergency Implications
The global pandemic and ensuing public health emergency changed
the landscape of client-care and an emerging paradigm shift from
face-to-face services to online remote services. In a brief period
between March 2020 and June 2020, a rapid and sweeping adoption
of virtual services occurred in several industries, including telehealth,
telemedicine, eCounseling, and eLearning. In response to the growing
epidemic, the Centers for Disease Control (CDC) issued guidelines
for infectious diseases and social distancing measures for which the
professions of speech-language pathology and audiology adhered to
via ASHA recommendations (ASHA, 2021a). This expansion included
speech-language pathology services via telepractice, which ensured
that clients received services while reducing the risk of transmitting
diseases from clinician to client and from client to clinician.

This rapid adoption created a window of opportunity to increas-
ingly educate telepractice adopters, stakeholders, clinicians, and
decision-makers on the present and future of telepractice services.
As clinicians rush to learn, adapt, and integrate telepractice services
into their respective caseloads, the strengths and needs of each of the
elements of telepractice have been exposed. This rapid adoption of
telepractice has revealed that setting up and establishing a tele­practice
program consists of much more than acquiring the equipment and
hardware; it also includes the very human aspects of clinician and
client connections. There is an opportunity to strengthen both the
technological and human/therapeutic elements of telepractice. Current
and future studies will provide a clearer picture of the impact of the

1.  An Introduction to Telepractice  9

pandemic on telepractice services and the impression that rapid adop-
tion may have on the retention and sustainability of these services.

Amid the pre-and post-COVID-19 landscape of increased use of
online, remote services to meet CDC safety standards, there is ample
opportunity for telepractice to become a more mainstream modality
of service. Still, and amidst a pandemic, when online services are
the prevalent option for many clients, the critical stakeholders (SLPs,
school administrators, outpatient clinics) continue to be confronted
with challenges in the future. There is ample opportunity within
the community of communication sciences and disorders scholars,
telepractice experts, and decision-makers to transition and include
telepractice services and to provide clear role and responsibility
guidelines in their involvement in sessions. In the United States, the
rush to implement telepractice in K–12 schools indicated a clear need
to transition to telepractice, and the fast pace of this transition was
evident. This clear and present paradigm shift and increased interest
could catapult telepractice into a mainstream service delivery model,
and research on the eHelper’s role is needed.

In response to the pandemic, the Centers for Medicare & Med-
icaid Services (CMS, 2020) allowed audiologists and SLPs to provide
select telehealth services to Medicare Part B (outpatient) beneficia-
ries for the duration of the public health emergency (PHE) (ASHA,
2021b). At the time of this publication, the PHE is expected to last
through at least the end of 2021. It is recommended that profession-
als continually check the ASHA guidelines as these rapidly changing
circumstances evolve.

Resources

Federal guidelines
n U.S. Department of Health and Human Services;
https://www.hhs.gov/
n Center for Disease Control and Prevention;
https://www.cdc.gov/

10  Telepractice:  A Clinical Guide for Speech-Language Pathologists

ASHA resources
n Telepractice Resources during COVID-19; https://www.asha​
.org/about/telepractice-resources-during-covid-19/
n State resources: State-by-State Tracking of Laws and
Regulations for Telepractice and Licensure Policy

Resuming In-Person Services

Some clinicians may wonder if and when to stop practicing teleprac-
tice and provide more in-person services. First and foremost, clinicians
should thoroughly review the Centers for Disease Control’s (CDC)
recommendations for healthcare and school workers before resum-
ing in-person services. In addition, ASHA, state, and local guidelines
and orders may apply and determine whether in-person services are
advised. When in-person services are resumed either on a hybrid
basis (a combination of in-person and online) or entirely in-person,
there are several considerations for both the clinician and client.

A clinician can take several steps when considering resuming
services. The first consideration will be the need for informal or
formal evaluation or reevaluation of the client’s skills. For many cli-
nicians, the choice to evaluate/reevaluate will begin with observation
of a client, either in the classroom setting, clinical setting, or social
setting (cafeteria, dining/lunchroom). In addition to observation,
gaining information from parents, caregivers, teachers, and other
related professionals (counselors, physical therapists, and occupa-
tional therapists) will be helpful. A clinician may also choose to reissue
a questionnaire or survey instrument distributed at the beginning of
the year to determine any changes in status or performance. Based on
observation and (re)evaluation results, clinicians may decide to revise
a student’s therapy plan, goals, or objectives. These goal revisions may
be needed to identify and target skills that showed regression during
the service interruption. In any and all events, telepractitioners will
need to resume therapy in the most efficient way to support clients
going forward.

1.  An Introduction to Telepractice  11

Some clients may request, or even insist, on being seen in-per-
son. In some circumstances, the clinician may be asked to determine
whether telepractice is the best option for the client, and should con-
sider several factors, including:

n Does the client have access to a telehealth platform, and is he
or she able to use it?

n If this is ongoing treatment, is the client making progress? Is
there a decline?

n Is the next phase in treatment feasible for continuing
remotely, or does it require in-person contact?

Notes and documentation are essential, especially if the client
insists on in-person services. Key documentation may include progress
notes, subjective-objective assessment plan (SOAP) notes, discussions
about the benefits of telehealth, plans for next steps, and rationale for
why providing services via telehealth is clinically appropriate.

Prior to the pandemic, telepractice existed. Clinicians in VA
hospitals, schools, and private practice chose to provide services
remotely. In fact, not everything related to telepractice can be linked
to a global pandemic, and not everything about speech pathology
during a pandemic is related to telepractice. Telepractice existed long
before this pandemic started, and was utilized by choice for over 15
years prior to the pandemic. Still, we currently need to consider the
circumstances of our past, present, and future to ensure the safety
of all. The Telepractice Preparation Quicklist (Figure 1–1) provides
an overview, as well as an easily accessible checklist of telepractice
considerations for clinicians considering telepractice services.

Summary

It is clear that telepractice is here to stay. Many SLPs found that they
enjoyed this form of service delivery and excelled at it (while others
could not wait to get back to in-person therapy). The clinicians that

12  Telepractice:  A Clinical Guide for Speech-Language Pathologists
Figure 1–1.  Telepractice Preparation Quicklist.

1.  An Introduction to Telepractice  13

were launched into telepractice with little to no training felt like it
was “sink or swim,” many thrived in this setting. That being said,
all clinicians must receive training in best practices for this service
delivery model, as is done whenever new methods are introduced or
research reveals improved models of service delivery.

The global pandemic certainly affected the rapid adoption of
telepractice. It facilitated clinician’s ability to provide services in all
settings, particularly in schools where students have IEPs (Individu-
alized Education Plans), which obligates them to continue providing
services outlined in these documents. Continuation of the use of
telepractice will impact not only what is happening today but certainly
well into the future. A global health emergency forced the profession
to adopt telepractice quickly, which allowed many more clinicians to
see the benefits of this service delivery model.

References
American Speech-Language-Hearing Association. (ASHA). (2021a).

Coronavirus/COVID-19 updates. https://www.asha.org/about/
coronavirus-updates/
American Speech-Language-Hearing Association. (2021b). Federal
public health emergency extended, expected through 2021. https://
www.asha.org/news/2021/federal-public-health-emergency-​
extended-expected-through-2021/
American Telemedicine Association. (2014), Core operational guide-
lines for telehealth services involving provider-patient interactions.
file:///Users/melissajakubowitz/Downloads/NEW_ATA-Core-
Guidelines.pdf
Burns, C. L., & Wall, L. R. (2017). Using telepractice to support man-
agement of head and neck cancer: Key considerations for speech-​
language pathology service planning, establishment, and evaluation.
Perspectives of the ASHA Special Interest Groups, (2), 139–146.
Cason, J. L., & Cohn, E.R. (2014). Telepractice: An overview and best
practices. SIG 12 Perspectives on Augmentative and Alternative
Communication, 23(1), 4–17.

14  Telepractice:  A Clinical Guide for Speech-Language Pathologists

Centers for Medicare and Medicaid. (2020). April 2020, https://www​
.cms.gov

Centers for Medicare and Medicaid. (2021). COVID-19 Emergency
declaration blanket waivers for health care providers. https://www​
.cms.gov/files/document/summary-covid-19-emergency-decla​
ration-waivers.pdf

Coufal, K., Parham, D., Jakubowitz, M., Howell, C., & Reyes, J. (2018).
Comparing traditional service delivery and telepractice for speech
sound production using a functional outcome measure. Ameri-
can Journal of Speech-Language Pathology, 27, 82–90 https://doi​
.org/10.1044/2017_AJSLP-16-0070

Houston, K. T. ( 2014). Telepractice in speech-language pathology.
Plural Publishing.

Kumar, S., & Cohn, E. R. (2013). Telerehabilitation. Springer
Malandraki, G. A., Arkenberg, R. H., Mitchell, S. S., & Malandraki,

J. B. (2021) Telehealth for dysphagia across the lifespan: Using
contemporary evidence and expertise to guide clinical practice
during and after COVID-19. American Journal of Speech-Language
Pathology 30(2), 532–550.
Short, L., Rea, T., Houston, B., Scott, S., & Forducey, P. (2016). Positive
outcomes for speech telepractice as evidence for reimbursement
policy change. Perspectives of the ASHA Special Interest Groups,
SIG 1(18, Part 1), 3–11.
Theodoros, D. (2011). Telepractice in speech-language pathology:
The evidence, the challenges, and the future. SIG 18 Perspectives
on Telepractice, 1(1), 10–21.
Tindall, L. (2012). The use of telepractice technology to provide
speech and language services to persons aging with communica-
tion disorders. Perspectives on Gerontology 17(3), 94–102.
Weidner, K., & Lowman, J. (2020). Telepractice for adult speech-​
language pathology services: A systematic review. Perspectives of
the ASHA Special Interest Groups, 5(1), 326–339.
Zahir, M. Z., Miles, A., Hand, L. & Ward, E. C. (2021). Information
and communication technology in schools: Its contribution to
equitable speech-language therapy services in an underserved
small island developing state. Language, Speech, and Hearing
Services in Schools, 52(2), 644–660.

2 Technology

Technology appears to be an ever-moving target as it contin-
ues to improve. The purpose of this chapter is to delineate the
current, minimum parameters for choosing appropriate technology
used in telepractice rather than recommend specific computers,
cameras, microphones, and so forth. Using the proper technology for
telepractice contributes significantly to successful teletherapy and
teleassessment services. Without suitable internet, a quality computer,
the right peripherals, and an appropriate videoconferencing platform,
services can derail quickly. In this chapter, computers, peripherals,
internet speeds, and access to applicable content is discussed, along
with setting up a space that lends itself to effective telepractice (Kumar
& Cohn, 2013).

Internet Speeds
To support videoconferencing platforms, peripherals, such as a
browser with numerous tabs open and running a videoconferenc-
ing platform, must meet a certain level of internet speeds to provide
good quality audio and video without significant lags. ASHA (n.d.)
states, “ . . . telepractice must be equivalent to the quality of service
provided in-person. . . . ” To ensure quality services, internet speeds
must be adequate so that the teletherapy is equal to in-person services

15

16  Telepractice:  A Clinical Guide for Speech-Language Pathologists

in quality. The ASHA Code of Ethics supports the use of telepractice
(Principle I, Rule N; Individuals who hold the Certificate of Clinical
Competence shall not provide services solely by correspondence but
may provide services via telepractice consistent with professional
standards and state and federal regulations [ASHA, 2016]) and indi-
cates that the technology utilized must support quality equivalent to
in-person services.

The internet speeds needed for various teleconferencing plat-
forms vary, but in general, minimum upload and download speeds of
1 to 5 megabytes per second are required. It is important to remem-
ber that this is just for the videoconferencing portion. Later in this
chapter, we discuss other peripherals that may affect speeds and band-
width, which must be considered when determining needed internet
speeds. Today, much of the United States has access to high-speed
internet. However, there remain many rural areas that do not. If either
the client or clinician does not have access to high-speed internet at
appropriate speeds, it can affect the quality of the services provided.
One thing that is known is that satellite internet does not support
videoconferencing platforms. It is too slow to work effectively for
telepractice. In these cases, telepractice is not an appropriate model of
service delivery. Table 2–1 lists popular videoconferencing platforms
and the minimum speeds needed to run them successfully.

Computer Specifications
For the clinician, any desktop computer or laptop should be sufficient
for teletherapy as long as it is less than 5-years-old and has regularly
updated software. As of this writing, the only computer that does
not appear to be as helpful for teletherapy is a Chromebook. The
Chromebook was not meant for use with videoconferencing technol-
ogy and that made it difficult to use the screen share feature with a
client. However, just recently, Chromebooks have been updated, and
it appears that some of the problems using videoconferencing may
have been improved. Both Macs or PCs are adequate for teletherapy.
According to Parsons (n.d.), the hard drive should be a Solid-State

2. Technology  17

Table 2–1.  List of Popular Videoconferencing Platforms With Minimum
Upload/Download Speeds

Platform Minimum Minimum Recommended
Name Upload Download Upload/Download
Speed Speed Speeds

ZOOM® 1 Mbps 1 Mbps 3 Mbps/2.5 Mbps

Google Meet™ 3.2 Mbps 1.8 Mbps 3.2 Mbps/3.2 Mbps
TheraPlatform 3 Mbps 3 Mbps Same as minimum

GoToMeeting® 1 Mbpss 1 Mbps 1 Mbps/1 Mbps or better

Doxy.me 500 Kbps 500 Kbps 7 Mbps/7 Mbps

WebEx® 2.5 Mbps 3 Mbps 5 Mbps/5 Mbps

VSee 200 Kbps 500 Kbps 1.5 Mbps/1.5 Mbps

Note:  All information here is taken from each of these website platforms.

Drive (SSD) as it runs faster than a traditional hard drive. Most new
computers come with this feature. Although SSDs tend to use smaller
storage sizes (around 128 GB), it is adequate for telepractice. If more
storage is needed, then using cloud storage can add to your capacity.
In terms of processing speed, a 2 GHz processor will work best. To
optimizing screen-sharing, a quad-core processor will be needed.
Four GB (gigabyte) RAM (this is the computer’s short-term memory)
is adequate, although 8 GB RAM will allow you to perform more
tasks at once while providing teletherapy. This will enable the clini-
cian to have more tabs open, use screen share, a document-sharing
camera, and so forth all at once while maintaining good speeds with
no hiccups (Parsons, n.d.).

When purchasing a computer for teletherapy, having one with
an ethernet port will provide faster internet speeds when compared
to Wi-Fi. With many of the newer computers, a USB adapter can
be directly connected to the internet. A faster internet connection
will facilitate better quality teletherapy services. Choosing a screen or
monitor with high resolution (higher than the standard 1920 × 1080
pixels) will assist with better video clarity. Webcams that come with

18  Telepractice:  A Clinical Guide for Speech-Language Pathologists

traditional laptops and desktops are typically sufficient for telether-
apy. However, higher resolution cameras can be purchased if there is
a need (more about cameras later).

Getting to know the type of device clients are using for services is
critical as it will impact the way they interact with the materials shared
online (Cason & Cohn, 2014). It is also essential for the clinician to
know how to do basic troubleshooting on their clients’ devices. If a
clinician has not had experience with a device the client uses, they
should obtain information, either through researching the device or
through practice with that device, to understand the client’s view.
Understanding the client’s perspective assists with decisions regarding
what materials to use and what features of the platform work, or do
not work, on specific devices. Smartphones are not the best option
for clients as their view is very limited, and they typically cannot view
both the video feed and shared screens. Phones also tend to have
smaller screens, and it may be difficult to read because print materials
will be small. Tablets are better but also have limited views, depending
on the specific device. In addition, the client may or may not be able
to access materials if they have a touch screen and may need to use a
mouse to activate shared materials.

Headsets
Headsets are essential for both the SLP and the client. A good quality
headset with a microphone is critical for hearing what the client is
saying and for the client to listen to the clinician. They also serve to
block out some background noise, which is helpful if the client or
clinician is not in a quiet setting. SLPs need to hear subtle differences
in speech production when working with clients with speech sound
disorders and those with language disorders, mainly when listening
for morphological aspects of language. There are many good-quality
headsets with boom-type microphones that work well. Choosing a
headset is very personal as people have different size heads and ears,
so it is best to try on a few to ensure they are not too snug or too loose.
They should be comfortable enough to be able to wear for several

2. Technology  19

hours at a time. In addition, the sound quality should enhance what is
heard and transmitted between the participants in a therapy session.

When working with clients in their homes or at a site like a
school with a facilitator sitting in on a session, clients can continue
to wear headsets. The family member or facilitator can also listen in
on a session by using a splitter. A splitter is a small device that plugs
into the computer and has ports to plug in more than one headset.
It allows more than one individual to hear the therapy session. The
splitter requires the appropriate connections for the computer and
these can be purchased wherever computer accessories are sold.

A question regarding headsets comes about when SLPs work with
clients who may have sensory or other issues that deter them from
wearing headsets. For those clients, it may be possible to desensitize a
client to tolerate headsets. However, if this is not possible, teletherapy
may still be used, with some caveats. Setting up the environment for
clients is crucial. The client’s environment should be a quiet area and
away from auditory and visual distractions and interruptions. This
will facilitate the client’s ability to hear the SLP clearly and to respond
without extraneous noise.

For clients with hearing aids or cochlear implants who are unable
to use a headset, it is essential to note that they can potentially pur-
chase a cord that connects their hearing device to the computer, or,
if they have Bluetooth available on their hearing devices, that can be
used for connecting to the computer sound.

Cameras
As noted above, the built-in cameras on most laptop and desktop
computers are more than adequate. However, if the video feed
quality does not meet personal expectations, purchasing an external
camera can improve the quality of the video feed. These external
cameras can serve more than one function and may help with cer-
tain aspects of teletherapy. For example, if you have both a built-in
camera and an external camera, the external camera may be utilized
to share documents. An external camera may help demonstrate phys-

20  Telepractice:  A Clinical Guide for Speech-Language Pathologists

ical actions for a client or give a wider-angle view of the clinician’s
setting for various engaging activities. A wide-angle camera may be
helpful on the client’s side if a parent-coaching model is being utiliz-
ed. It would allow the client to put their device in one place while
allowing the clinician a broader view of the client and family in
their home.

Videoconferencing Platforms
Videoconferencing platforms are plentiful, with more being devel-
oped and upgraded as technology improves. This section will discuss
essential tools within a videoconferencing platform when determin-
ing which one to choose. It should be noted that the purpose of this
section is not to recommend specific platforms but to give the reader
tools to assess the various platforms available to determine the best fit
for both clinician and client. These platforms have changed consid-
erably over the last few years, and there are now several SLP-specific
platforms. It is up to each clinician to establish which features are
relevant for their clients in order to choose the platform that will meet
the needs of those they serve.

To establish which platform will work best, the clinician should
look at their client population for age, level of functioning, hearing
and visual ability, attention to task, ability to sit quietly in front of a
camera, communication characteristics, availability of technology for
the client, and availability of a caregiver to support the client (ASHA,
n.d.). In addition, each clinician must analyze the type of therapy and
therapy materials they typically use to determine if the platform will
support the kind of therapy and materials they usually utilize. Col-
lecting this information will then determine which platform meets
their needs.

First and foremost, the platform must be easily accessible for the
client. Being unable to access the platform with a quick link could
potentially derail teletherapy before it even gets started. Many video-
conferencing platforms are web-based, which are more easily accessed
if it allows the clinician to send a link to the client, who can then just
click on the link to access the platform. It is also easier for a client if

2. Technology  21

they do not require a download before beginning the process. When
researching platforms, it is important to note how the platform is
accessed as it must be simple and easy to get to a therapy session.

A commonly used feature in teletherapy is screen-sharing. It
is a tool that allows SLPs to share materials. Screen-sharing is very
functional for SLPs. It will enable them to share a wide variety of
interactive websites typically used in teletherapy and allow SLPS
to share any materials they have saved on their computers, which
help engage clients, whether they are children or adults. There is one
instance where screen-sharing may not be necessary, and that would
be one in which the platform has enough built-in materials to serve
all the clients on an SLPs caseload.

Another feature is a digital whiteboard and annotation tools.
These features allow a clinician to bring up a whiteboard (like a white-
board in a classroom) and interact with a client using the annotation
tools. A client or clinician can draw, type, or write on the screen while
both are viewing the whiteboard. This is an excellent therapy tool and
assists with improving the interactivity of teletherapy. Some of the
platforms include stamps, shapes, and other fun objects that can act
as reinforcements or as game pieces when appropriate. The white-
board also works in the background when screen sharing a website or
document with a client. Having a whiteboard with annotation tools
allows for additional interaction with clients and serves to motivate
some clients.

The following features are good to have but not necessarily “must-
haves,” depending on the client population being served. Having
the ability to enable a waiting room and passwords improves com-
pliance with Health Insurance Portability and Accountability Act
(HIPAA) and Federal Education Rights and Privacy Act (FERPA).
These assist with additional security and ensure that the virtual
therapy room is safe, in that only authorized users may enter. Some
platforms also have polling features that can add to client engagement.
Polls can be used in therapy as a quiz to determine client knowledge
about specific topics they are working on or to break up therapy
sessions and another engagement tool. Closed captioning can be
helpful when working with clients who have hearing issues. Closed
captioning is particularly useful when working with people with
hearing impairments.

22  Telepractice:  A Clinical Guide for Speech-Language Pathologists

Some platforms also include features such as calendaring,
billing, documentation, and built-in therapy materials. It is essential
to determine if these are features that you will use and if the cost
of the platform with these features is worth the investment. Currently,
there are no platforms that the SLP can pick and choose the features
they need or want. Using a platform with features that you don’t use
often, or are not helpful for their practice, might be costly. When
determining the best platform, ask yourself how often you might use
each feature and whether the cost justifies having unused features.

One last aspect to consider in a platform is how one will assess
clients. Before March 2020, limited formal speech and language
assessments were available in a digital or electronic format (Waite
et al., 2010). In the past year, many publishers of SLP assessment
materials have moved their test easels to an online form. Depending
on which tests the SLP typically uses, it is crucial that the digital or
electronic version of the test can be easily used in a videoconferenc-
ing platform. The SLP must think about whether there is a need to
modify test instructions or how the client responds (pointing, using
the mouse to point, etc.) as this can affect the outcome of the test.
Chapter 4 contains more specific information on the administration
of assessments. The most important thing to remember here is deter-
mining if the evaluation is compatible with the used platform.

Choosing a platform entails looking at each of the features offered,
the types of clients served, the ages of the clients, and how these fea-
tures fit into the SLP’s individual practice. As technology improves
and develops, we will continue to see growth in what is available in
the future. Many of the innovations in the works include Artificial
Intelligence (AI) and Virtual Reality (VR), which may impact how we
provide service and enhance what we currently do as SLPs.

Service Delivery Models
Audiology and speech-language pathology services are person-​
centered. The clients served are and have always been diverse, includ-
ing individuals with significant needs or groups with similar goals and

2. Technology  23

objectives. The clients served in person and via telepractice can be of
any age, race, gender, sexual orientation, language, ethnic, religious,
occupational, and socioeconomic group from all geographic areas.
Although these facts remain the same, the medium in which we serve
has changed and become more diverse. The following sections review
the current and future modalities used with or in lieu of telepractice
technology and Figure 2–1 illustrates service delivery models.
Face-to-Face
An evaluation of telepractice service delivery must include face-to-
face services. As a profession that values human communication,
the traditional face-to-face model continues to be a dominant goal
throughout history. Providing screening, assessment, consultation,
diagnostic, and treatment/intervention are part of the face-to-face ser-
vices provided, from schools, hospitals, clinics, rehabilitation nursing
care facilities, research laboratories, and private practices. One-on-
one and groups of clients in-person and in classrooms, therapy rooms,
or even the client’s home continues to be a professional standard.
Blended Learning
The blended service delivery model is more widely used in education,
but there are some applications to telepractice in speech-language

Figure 2–1.  Service delivery models.

24  Telepractice:  A Clinical Guide for Speech-Language Pathologists

pathology. Blended learning is an approach to education that com-
bines online educational materials and opportunities for interaction
online with traditional in-person classroom methods (CapstoneCore,
2021). Blended learning requires the physical presence of both the
teacher and client, with some elements of client control over time,
place, path, or pace. While clients still attend “brick-and-mortar”
schools with a teacher present, in-person classroom practices are
combined with computer-mediated content and delivery. Although
blended learning is not commonly used to describe telepractice ser-
vices in speech-language pathology, it is something used in education,
therefore, it could be something SLPs should be aware of.

Hybrid
Hybrid speech-language therapy services integrate in-person sessions
and online/asynchronous or synchronous sessions, techniques, and
activities. Individual clients or groups of clients may benefit from
hybrid services for various reasons, including the distance between
therapist and client, time constraints, cost, and convenience. When
face-to-face sessions and teletherapy sessions are combined, clients
receive personal interaction with the therapist and receive online
therapy sessions and materials that address the client’s goals and
objectives.

Hybrid learning uses online components for instruction,
therapy, and learning that replace face-to-face time with the teacher
or clinician (National School Boards Association, 2021). Examples
of early hybrid learning approaches occurred in the home environ-
ment. As hybrid learning has evolved and taken shape, it shifted to
the classroom where clinicians and teachers were both in-person and
online as schools shifted from an all-remote approach to a combi-
nation of virtual and in-person instruction and services. As we look
to contemporary hybrid models, the trend is now to supplement
multiple solutions for student success. In some settings, this means
having clients at home part-time and in-class part-time. Other
districts have chosen to keep certain ages, vulnerable populations,

2. Technology  25

groups, or grades at home full time and allow younger children to
return in person.

Hybrid Versus Blended Learning
The terms “hybrid learning” and “blended learning” are often thought
of as synonymous, but these terms are not identical. A distinction
about blended learning is its inclusion of online materials and tools
that supplement learning rather than replacing the face-to-face
experience (Konopelko, 2021). Blended learning often includes new
and innovative initiatives such as project-based learning that add
multimedia resources to common coursework and allow clients to
self-direct some of their education and instruction.

Hybrid classes, in contrast, take these online tools and provide
them to clients through remote learning websites and online educa-
tional management systems for use outside of the traditional school
environment. When comparing hybrid learning versus blended
learning, if tools augment face-to-face frameworks, it is considered
blended learning and if tools facilitate the replacement of in-person
instruction, it is considered hybrid.

Telepractice
When defining telepractice, the traditional definition includes “use
of telecommunication technology” to provide speech-language
pathology services. This technology can include the internet, video­
conferencing, networks, and digital communication to connect the
client and clinician. When considering online only, the clinician
provides services online only in lieu of face-to-face or in-person ses-
sions. Online-only sessions may be a combination of synchronous
(real-time) or asynchronous components. However, for therapeutic
sessions, most online-only telepractice sessions utilize synchronous
sessions where the client and clinician work together using videocon-
ferencing technology in real-time.

26  Telepractice:  A Clinical Guide for Speech-Language Pathologists

Determining the Service Delivery Model
That Best Suits the Client
With the increased use of telepractice service delivery models, thera-
pists, parents, and clients are left to determine which model best suits
their needs. Within these considerations is the consideration of the
clients’ social, emotional, and mental health needs. With the need
for social distancing and school and clinic closures, providing a safe
and inclusive learning environment was paramount. Within this goal,
and addressing the impact of COVID-19 on clients’ opportunity to
learn, clinicians were faced with the delicate balance of supporting the
educators and staff ’s well-being with clients’ well-being and stability.

As the result of increased online services and distance learning
education, professionals have experienced disruptions in learning,
physical isolation, and disengagement from school, peers, and family
members, negatively affecting their mental health. The ongoing and
still unpredictable impact of COVID-19 has contributed to client
experiences that are far from universal—with underserved clients
experiencing a disproportionate burden of the pandemic. As a result,
many clients might require additional supports and interventions.

In addition, the full impact of clients facing adverse experiences
before, during, and after the pandemic has yet to be fully realized.
These experiences include homelessness and lack of consistent health
care that might disproportionately affect clients from low-income
backgrounds, clients of color, English learners, and clients with dis-
abilities. These adverse experiences may also create barriers to access
and participation in programs and services. School leaders, educa-
tors, and clinicians who work with clients with these backgrounds
should acknowledge the intersectionality (the overlapping identities)
among these groups. This framing will help all that are involved in
their care understand the multiple layers of disparities and complex-
ities encountered by clients, including homelessness, foster care, the
juvenile justice system, and the disproportionate impact COVID-19
has had on these clients.

Although adverse experiences can have significant effects on
clients, the learning environments, and especially online learning
environments and conditions such as telepractice, can be custom-

2. Technology  27

ized to assist clients in overcoming these effects. Improving academic
outcomes for clients requires nurturing each of these areas of devel-
opment in asset-oriented and personalized ways to meet clients where
they are, as they return to school.
Addressing Absenteeism
The academic and social-distancing disruption of COVID-19 has
been traumatic for clients and their families, educators, and therapists
alike. For significant portions of 2 academic years, what it means to
be “in school” and the routines, expectations, and norms associated
with those routines have vastly differed from what most clients have
ever experienced. School leaders, educators, and staff should ensure
physically, socially, and emotionally safe communities that prioritize
creating environments that support clients and respond to the trauma
experienced by many clients as school buildings reopen for in-person
instruction. It is almost certain that some clients in every school will
require support to address the isolation, anxiety, and trauma they
have experienced.

As more schools reopen for in-person instruction, and services
via telepractice decrease or stabilize, districts and schools are revisit-
ing their school safety and inclusiveness approach after the extended
absence due to COVID-19. Safe and inclusive schools can provide the
support required to reengage those clients most disconnected from
school during the pandemic.

Future Directions
Some may believe that hybrid learning is a temporary solution. These
models are likely a new normal. Several elements of hybrid learning
will remain as schools prepare for a return to the classroom, and this
could take the form of families opting for at-home learning out of an
abundance of caution, or schools choosing a partially hybrid model to
reduce classroom overcrowding and improve one-on-one interaction.

28  Telepractice:  A Clinical Guide for Speech-Language Pathologists

Clinicians and educators need to embrace the hybrid shift as a
foundational change to be accepted and absorbed into the future of
our clients. Schools will increasingly need to be creative and shift the
way clients learn and how teachers provide guidance. This approach
isn’t without challenges, given the many intangibles, funds, training,
and creative minds needed to support hybrid learning.

Strategies to Improve Telepractice Models
Telepractice, such as online teaching and learning models, requires
consistent access to the internet. Telepractice services are the most
successful when clinicians receive targeted training and support,
especially when troubleshooting technical challenges that may arise.
As clinicians become more familiar and experienced with telepractice,
the daily challenges may have less to do with remote and hybrid learn-
ing itself and more to do with training and knowledge of new tech-
nologies that emerge. Continuing education, training, and support
are critical for both the clinician and clients’ success.

Future Directions in Telehealth
The use of technology in rehabilitation disciplines in general, and
in communication disorders in particular, is increasing. The drive
for technological innovation in rehabilitation is based on the need
to expand existing therapeutic options and intensify intervention by
creating opportunities for home-based practice that is easy to use
and highly engaging. The recent proliferation of handheld devices
and web-based applications, which might make intervention services
more accessible to individuals of all ages and levels of technological
expertise, supports this demand.

Beyond the engineering and programming of these devices,
however, limited attention has been given to the systematic evalua-
tion of a given technology’s feasibility, usability, and effectiveness in
facilitating rehabilitative change. This step in evaluating technology is

2. Technology  29

a prerequisite to designing future randomized control trials (Klasnja
et al., 2011).

The future of rehabilitative technologies includes virtual reality,
serious games, and augmented visual feedback approaches for speech
rehabilitation. Preliminary data on the feasibility and potential ben-
efits of using these treatment approaches to improve speech produc-
tion skills in children and adults is still in development. However,
these technologies collectively provide early evidence that augmented
visual feedback regarding acoustic, vibratory, or kinematic properties
of speech facilitates communication change in very different clinical
populations.

Artificial Intelligence
On a similar note, McAllister Byun and Tiede (2017) developed an
iOS app, “StaRt,” that provided visual, acoustic feedback based on the
real-time linear predictive coding spectrum. The goal of the app was
to promote correct /r/ productions. The acoustic target—a low third
formant—was visually identified on the spectral envelope display. In
addition to the description of the method, the article includes pilot
data for an adolescent girl who was instructed over a 20-week treat-
ment period. She was taught to reach the target low third formant
by adjusting her articulation. Both stimulus complexity and amount
of feedback varied to enhance learning. A speech-language pathol-
ogist facilitated the use of the StaRt app in the context of a clinic.
Overall results show that, for this client, app-based biofeedback was
a potentially effective alternative to more costly systems with limited
clinical availability. The findings also highlight the challenges one
might encounter in achieving correct speech sound production gen-
eralization when biofeedback is withdrawn.

Yunusova et al. (2017) studied the effect of augmented visual feed-
back on tongue movements in individuals with Parkinson’s disease.
These investigators were interested in the impact that augmented
feedback would have on acquiring and retaining simple instruc-
tions for increasing the extent of articulatory movements during the

30  Telepractice:  A Clinical Guide for Speech-Language Pathologists

production of sentences. The tongue movements were recorded with
electromagnetic articulography and displayed via games developed
in-house using the Unity®game platform. The overall extent of the
tongue motion during each sentence production was quantified via
the articulatory working space and displayed immediately after the
sentence was spoken. The challenge of the task was regulated by
adjusting the limits of performance. Eight out of nine participants
with hypokinetic dysarthria showed an increase in the magnitude of
speech movements following this intervention, once again demon-
strating the potential benefits of augmented visual feedback treatment
for improving speech production.

The three studies in this series of reports have several common
threads. First, the experimental literature supported the positive effect
of augmented visual feedback for enhancing motor learning (Sigrist
et al., 2013). Second, these studies used instrumental signals to rep-
resent speech events and define treatment targets precisely. Because
objective data can be collected before, during, and after the intervention
with the same technology, the effectiveness of the intervention can be
reliably and efficiently established. Third, each of these studies used at
least some elements of the “serious games’’ format, which uses games
to achieve a “serious” goal (e.g., health outcome), thus facilitating
engagement and motivation during the treatment process (Lohse et al.,
2013). Finally, all these studies provided some discussion of usability
issues by documenting user experiences with the intervention.

These usability observations are critical to the development of
the next iteration of game-based speech intervention technologies.
It has become increasingly clear that innovative technology may be
useful in bringing about therapeutic change. However, a specific
approach might be effective for one individual but not necessarily
for another. It is also likely that a given technology may improve an
individual’s abilities at one stage in the treatment process but not at
all stages of intervention. Recommendations regarding candidacy
(e.g., diagnosis, severity of impairment, cognitive status, demographic
and social factors) need to be further evaluated to improve treatment
outcomes. As technological advances continue to appear on the clin-
ical horizon, researchers must not lose sight of the essential clinical
questions in our profession: whom to treat with a given technology,

2. Technology  31

when to treat, and for how long. The articles in this series begin to
address these questions using a format of pretrial feasibility and pilot
efficacy studies. Investigations designed to provide proper controls at
the case and group levels, and the well-designed randomized control
trials are indicated as the next steps in evaluating these technologies.

Speech Recognition
Speech recognition (SR) is the process whereby a computer with
sound processing hardware responds in predictable ways to spoken
commands and/or converts speech into text (Venkatagiri, 2002).
The emerging applications of SR technology include applications for
dictation, articulation training, language and literacy development,
environmental control, and communication augmentation.

SR is a part of the larger and burgeoning field of natural language
processing (NLP) that strives to develop applications that decipher
the meaning of spoken utterances or strings of text and respond with
well-formed spoken utterances or text (Jurafsky & Martin, 2000).
Applications of NLP include spelling and grammar checking, retrieval
of information through interaction with artificial conversational
agents (dialog engines), machine translation, automatic text summa-
rization, and text data mining. This work presents a tutorial on SR and
its present and potential applications in communication disorders.

An additional application of SR technology, which is still in the
beginning stages, is voice biometrics—the process of speaker iden-
tification by voice and speech characteristics (Juang et al., 1995).
Although there are individual variations in its implementation, the
technology is typically based on estimating the selected parameters
of the three-dimensional vocal tract geometry by analyzing a sample
of the user’s voice with a mathematical procedure called linear pre-
dictive coding (LPC) cepstral analysis. Because identification is based
on vocal tract shape rather than voice characteristics, small changes
in voice quality, such as those due to a cold, do not affect the accuracy
of identification.

Computers work with numbers, and therefore the first step in
speech recognition is to digitize speech. Speech is a pressure wave

32  Telepractice:  A Clinical Guide for Speech-Language Pathologists

in the air whose magnitude varies continuously in time. This analog
wave is captured by a microphone, which converts it into an analog
electrical wave. The computer’s sound card samples the electrical
signal at preset time intervals (sampling frequency) to assign values
of magnitude within a preset range (quantization). Speech recogniz-
ers may use a sampling frequency between 8 and 16 kHz (8,000 to
16,000 samples per second, representing speech frequencies between
4 and 8 kHz), and quantization levels between 8 and 16 bits (256 to
65,536 different values to represent pressure variations). The higher
the number for sampling and quantization, the better the resulting
digital representation of speech (O’Shaughnessy, 1987). However,
higher values for sampling and quantization result in a larger amount
of digitized data and require faster processors and larger amounts of
computer memory. The broad steps required for speech recognition
are shown in Figure 2–2.

SR technology holds great promise and potential hurdles for
people with communication disorders. It is reasonable to assume that
in the future, due to (1) technological advancements, (2) reduced cost
of powerful computers, and (3) potential savings in cost and effort,
the use of SR at home and work as a computer input method will be
as ubiquitous as the mouse and the keyboard are today. The spread
of information-dispensing kiosks in offices and public places (e.g.,
airports and malls) and the increasing use of SR-based automated

Figure 2–2.  A model for speech recognition.

2. Technology  33

customer service systems by businesses will, in the future, require that
even people who do not normally use computers may need to “talk”
to them frequently.

There is little research on how the increasing use of SR at home,
at work, and in public places will affect those with speech, language,
and hearing disorders. Many of these SR applications are speaker-​
independent systems based on non-disordered speech data, and
therefore may be largely unsuitable for people with communication
disorders. The language complexity of training materials included
in speaker-dependent systems mostly targeted for business appli-
cations makes them less useful for young children and adults with
moderate to severe cognitive deficits. Speech-language pathologists
and audiologists need to (a) document difficulties faced by people
with communication disorders when using speaker-independent SR
applications, (b) develop a set of “work-around” techniques that help
people with communication disorders cope with what will almost cer-
tainly be a deluge of business-related SR applications, and (c) engage
and encourage technology developers to produce SR applications that
accommodate people with communication disorders.

Ten Tips to Make Connections Using Technology
These tips are designed to help the clinician make connections in any
service delivery model that includes technology. Now, more than ever,
clients need and require the social and emotional connection that is
crucial to successful therapy. Beyond goals and objectives, clients see
connections regardless of the modality. As SLPs are navigating their
buildings’ reopening since the COVID crisis, the hybrid model—a
compromise that attempts to find a middle ground among groups
who want in-person instruction and those who want remote instruc-
tion—is a popular reopening strategy. These tips for technology and
telepractice may be applied across settings and populations:
1. Get to know your clients and build community online as

you would in person. Similar to the in-person therapeutic

34  Telepractice:  A Clinical Guide for Speech-Language Pathologists

experience, the clients deserve to learn together in a welcoming
and inviting space for all participants. Briefly check in with
clients at the beginning of each telepractice session to establish
empathy and builds trust.
2. Don’t assume that clients are comfortable in the online,
telepractice environment. Not all clients are comfortable
around their peers in person or online.
3. Be honest with your clients. If you aren’t sure how a new digital
activity works, tell them. Invite clients to showcase their talents
with a tech feature or offer an idea that may work better for
their classmates and you.
4. Know your limits but don’t be afraid to let your clients know
that you don’t have all the answers. Sincerity and vulnerability
are virtues in person and via telepractice.
5. Allow clients to show their participation beyond turning on the
camera or talking on screen. Offer clients alternative means for
participating. Using a chat feature, crafting group discussion
questions, or other nonverbal are alternatives ways to commu-
nicate and participate that do not require speaking or appearing
on camera.
6. Don’t force clients to “participate” in ways that suit your
preferred style of communication. Mandating constant partici-
pation can cause a client to feel anxious or stressed, resulting in
a client choosing not to attend class altogether.
7. Ask for client input. Use this feedback to navigate the kinds of
activities and strategies that work best for them in the teleprac-
tice environment. Their voices and ideas should be part of their
new educational experience.
8. Don’t make assumptions about clients’ familiarity with tech-
nology. Some clients have limited access to technology, and
they may be embarrassed to share this information with others.
Avoid phrases such as, “You’re young, and you use apps all the
time.” Not all technological experiences are equal.
9. Be patient with yourself and your clients. Focus on what you
can present successfully, one session at a time, and ask for help
if you need it.

2. Technology  35

10. Continue to develop your skills in all settings—in person,
blended, hybrid, and online. Learning is part of this therapeutic
process. Start with what works best for you and slowly add new
things at a pace that makes sense for you and your clients.

References
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