36 Telepractice: A Clinical Guide for Speech-Language Pathologists
McAllister Byun, T., & Tiede, M. (2017). Perception-production
relations in later development of American English rhotics. PLoS
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2021/june/transform-environment-transform-learning
O’Shaughnessy, D. (1987). Speech communication: Human and
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1818–1825.
3 Models of
Service Delivery
Introduction
The traditional and most common setting for speech-language
pathologists is the in-person model of service delivery. The
SLP meets one-on-one or small groups of clients in the traditional
in-person model of services where all parties are located in the same
physical location (e.g., designated Speech room in a school). The SLP
is primarily responsible for the client’s goals, objectives, and lesson
plan for each session. There is a long-standing history of research
regarding the effectiveness of the in-person delivery model to treat
communication disorders (Cleave et al., 2015). Likewise, it is the
standard method of treatment taught in graduate schools and clinical
practicum programs as illustrated in Figure 3–1.
The telepractice model differs significantly from the in-person
model of service delivery. In the telepractice model, the SLP is in a
different location and connected to the client via the internet using
synchronous (live) videoconferencing software, hardware (e.g., com-
puter, laptop), and software (word processing, educational programs).
The SLP, client, and eHelper may utilize additional physical equip-
ment, such as a headset, tablet, applications (apps), or various digital
tools (e.g., whiteboard, screen sharing) to enhance the telepractice
services for a more interactive therapeutic experience as illustrated
in Figure 3–2.
37
38 Telepractice: A Clinical Guide for Speech-Language Pathologists
Figure 3–1. In-person model of speech-language pathology.
A Review of Literature and Telepractice Research
In comparison to published research across the scope of practice of
speech-language pathology and communication sciences and disor-
ders, telepractice research is far behind in scope and breadth. Still, the
number of publications increases each year. The United States leads
in published research on telepractice (32.03%). However, Australia
is a close second at 29.12% of published articles (Molini-Avejonas
et al., 2015).
In the telepractice model, the SLP’s distance from the client is
a significant difference between in-person and telepractice speech-
language pathology. Research on telepractice has evolved, beginning
with using the landline telephone, to the use of virtual reality and
artificial intelligence technology (Tadeusiewicz & Wszolek, 2004)
to deliver services. One of the first published studies investigating
speech-language services delivered through telepractice was by Vaughn
(1976). This early research in telepractice included using a telephone,
connecting the SLP to provide language treatment to a remote client to
provide language treatment. Since that time, telepractice has evolved
to utilizing videoconferencing technology and high-speed internet
access connecting clients to clinicians in various settings, including
rural and underserved populations (Lowman & Kleinert, 2017).
39
Figure 3–2. Telepractice model of speech-language pathology. Based on Heyman (2018).
40 Telepractice: A Clinical Guide for Speech-Language Pathologists
The University of Queensland has been a leading international
force in published studies on telepractice. The studies have included
analyses and studies on assessment and treatment of acquired neuro-
genic disorders, including Parkinson’s disease. Theodoros et al. (2006)
studied the Lee Silverman Voice Treatment (LSVT) and patients
diagnosed with Parkinson’s disease via telepractice. The methodol-
ogy included real-time videoconferencing with a high-speed inter-
net connection. A total of 10 subjects were included in the study,
all diagnosed with dysarthria. Each subject was treated via teleprac-
tice sessions for 16 sessions. Not all areas resulted in improvement.
However, significant advances were found after completion of the
program for sound pressure levels, vowel prolongation, reading, and
conversational monologue.
Tele-AAC is used to provide services to clients who may lack
access to in-person AAC services. Tele-AAC combines and integrates
AAC assessment and treatment while implemented via telepractice
(Hall & Boisvert, 2014). Components of tele-AAC include SLP, equip-
ment (computer/laptop, webcam, AAC device, internal microphone/
headset), eHelper (paraprofessional or parent), online setting internet
platform/connection, and the client. SLPs use existing and emerging
technologies, including telepractice, to connect individuals in need
of AAC services. Hall (2013) completed an investigation of tele-AAC
services. The study compared the effectiveness of tele-AAC with the
traditional in-person model. Participants in the study were paired
with experienced, licensed clinicians to provide the tele-AAC ser-
vices. The author compared the tele-AAC treatment with treatment
in the traditional in-person setting. Results revealed no significant
difference between the number of spontaneous and prompted pro-
ductions in the participants between the in-person onsite and tele-
AAC settings. Most notably, client productions via telepractice were
consistent with the in-person setting.
Currently, the most common setting for telepractice is in the
K–12 school setting (ASHA, n.d.a). A confounding factor contribut-
ing to the use of telepractice in school settings is a shortage of SLPs in
K–12 schools (ASHA, n.d.b). Telepractice research has demonstrated
positive results with school-age and adult populations. In addition,
there is emerging research on the assessment and treatment across the
3. Models of Service Delivery 41
scope of practice, including articulation disorders (Waite et al., 2006),
autism (Boisvert, 2012), and language disorders (Waite et al., 2010).
The use of telepractice for adult and neurogenic speech disorders
may address the scope of practice and disorders, including aphasia,
aprosody, apraxia of speech, dysarthria, and dysphagia. Similar to
pediatric and school populations, the research is mainly emerging.
Within these studies, telepractice, telehealth, and telepractice were
used to describe the remote delivery of services to clients. An article
by Cherney and van Vuuren (2012) provided a literature review of the
studies of adults diagnosed with communication disorders treated via
telepractice. Studies were reviewed between the years 2000 and 2012. As
part of the findings, it was determined that telepractice had been used
to assess and treat disorders, including dysarthria, aphasia, apraxia,
and mild Alzheimer’s disease. Results indicated that telepractice was
a valid method of delivering speech and language services.
Telepractice has been used by several sections of the military
and Veteran’s Affairs since World War II. Specifically, telepractice
has been used in the treatment, rehabilitation, and recovery of com-
bat-wounded soldiers when deployed. The advances in technology
have also influenced civilian hospitals and clinicians to provide care,
education, and support to patients with traumatic brain injury (TBI) via
telepractice. Telepractice plays a critical role within the Department of
Veterans Affairs Health System and allows for the treatment of patients
who may have barriers to obtaining treatment (e.g., location, economic
status, disability). A benefit of telepractice to the veteran population is
increasing access to care for many veterans who would otherwise not
have access. Specifically, Veterans Affairs telepractice programs have
been shown to reduce hospitalization and length of hospital stays while
improving the quality of life for veterans (Girard, 2007).
Treatment and assessment of TBI for veterans via telepractice is
an area also being explored by the federal government. A bill has been
proposed to the United States Congress to improve detection of mild
and moderate TBI by implementing an objective computer-based
assessment protocol to measure cognitive functioning before and
after deployment. If passed, this would provide a wealth of pre-
post knowledge of head injuries that may otherwise go undetected
or reported. Telepractice is widely used to identify and aid in the
42 Telepractice: A Clinical Guide for Speech-Language Pathologists
treatment, rehab, and recovery of combat-wounded soldiers. These
advances are transforming the way clinicians provide care, education,
and support to patients with TBI. The same assessment tool would
be used across branches of the military and for every service member
who will be deployed and has been deployed.
Hines et al. (2015) investigated perceptions of SLP’s who transi-
tioned from the in-person delivery model to the telepractice delivery
model. The researcher found that SLPs reported initial skepticism
about telepractice setting as a delivery model. In addition, the SLPs
consistently compared their clinical experiences in the face-to-face
setting with their experiences in the telepractice setting. The study
showed that the SLPs’ transitions to the telepractice setting were
highly influenced by their ability to connect positive experiences in
the in-person setting to the telepractice setting. In summary, the SLPs’
transition experiences with telepractice were also influenced by their
relationships with clients, ability to collaborate with school staff, and
their use of technology. Table 3–1 lists a brief review of published
telepractice research across the scope of practice of speech-language
pathology.
Client Candidacy
As ASHA notes (ASHA website), clinical services “are based on the
unique needs of each individual client,” which is the guideline that
SLPs use with in-person services. With telepractice, SLPs need to
keep this in mind as they determine whether or not telepractice is
an appropriate service delivery model for each client, individually, as
would be done in person. SLPs are decision-makers when it comes
to their clients: they determine qualification for services, frequency,
and duration of services, whether to place the client in individual or
group sessions, and so forth. In the same way, SLPs ascertain whether
teletherapy is an appropriate model for each client based on a number
of aspects (Tindall, 2013). Evaluating the benefits and challenges of
the telepractice service delivery model, along with other options, is
imperative when analyzing each client’s needs.
Table 3–1. Evidence-Maps for Telepractice Design
Author/ Date Title Systematic review
Boisvert Telepractice in the assessment Clinical trial,
et al., 2010 and treatment of individuals experimental
with autism spectrum disorders: Exploratory
A systematic review Qualitative
Ciccia et al., Identification of Qualitative
2015 neurodevelopmental disabilities
in underserved children using Exploratory
telehealth Quantitative
Coufal et al., Comparing traditional service Qualitative
2018 delivery and telepractice for
speech sound production Systematic Review
continues
Fairweather Speech-language pathology
et al., 2016 teletherapy in rural & remote
educational settings: Decreasing
inequities
Freckmann Clinicians’ perspectives of the
et al., 2017 therapeutic alliance in face-to-
face and telepractice speech-
language pathology
Isaki & Provision of speech-language
Farrell, 2015 pathology telepractice services
using Apple iPads
Grogan- A comparison of speech sound
Johnson intervention delivered by
et al., 2013 telepractice and side-by-side
service delivery models
Hill & Breslin, Refining an asynchronous
2016 telerehabilitation platform for
speech-language pathology:
Engaging end-users in the
process
McGill, Telepractice treatment of
Noureal, stuttering: A systematic review
et al., 2018
43
Table 3–1. continued Design
Author/ Date Title
McDuffie Early language intervention using Single-subject
et al., 2016 teleconferencing: A pilot study design
of young boys with Fragile X
syndrome and their mothers
Molini- A systematic review of the use of Systematic Review
Avejonas, telehealth in speech, language
Rondon- and hearing sciences
Melo, et al.,
2015
Neely, Fidelity outcomes for autism- Systematic Review
Rispoli, focused interventionists coached
et al., 2017 via telepractice: A systematic
literature review
Overby, 2018 Stakeholders’ qualitative Exploratory
perspectives of effective
telepractice pedagogy in speech-
language pathology
Parsons, Parent-Mediated intervention Systematic Review
Cordier, training delivered remotely for
et al., 2017 children with Autism Spectrum
Disorder living outside of urban
Areas: Systematic review
Rudolph & Telepractice vs. onsite treatment: Systematic Review
Rudolph, Are outcomes equivalent for
2015 school-age children
Snodgrass Telepractice in speech-language Policy/Position
et al., 2017 therapy: The use of online statement
technologies for parent training
and coaching
Sutherland, Telehealth and autism: Systematic review
Trembath, A systematic search and review
et al., 2018 of the literature
Taylor, A review of the efficacy and Systematic review
Armfield, effectiveness of using telehealth
et al., 2014 for paediatric speech and
language assessment
44
3. Models of Service Delivery 45
Table 3–1. continued Design
Author/ Date Title
Tucker, 2012 Perspectives of speech-language Qualitative
pathologists on the use of
telepractice in schools: The
qualitative view
Wales, The efficacy of telehealth- Systematic review
Skinner, delivered speech and language
et al., 2017 intervention for primary school-
age children: A systematic review
Whitehouse, A national guideline for the Recommendations
Evans, et al., assessment and diagnosis of for assessment
2018 Autism Spectrum Disorders in
Australia
First, a review of each state’s regulations is in order to determine
whether or not telepractice is an acceptable model of service delivery
for clients. As of this writing, there are states that may limit telether-
apy, have restrictions on whether or not SLPAs (speech-language
pathology assistants) may provide services, and may require you to
register or obtain a license in the state where the client is receiving ser-
vices. Once it has been determined that telepractice is legal in the state
that the clinician provides services from, as well as the state the client
is receiving services, the next step would be to determine if the client
is a good candidate for this service delivery model (ASHA, n.d.a).
Because of the limits in the current body of research, ASHA
(website) notes there are four areas to be taken into consideration
when determining client candidacy. These include physical and
sensory characteristics, cognitive, behavioral, and/or motivational
characteristics, communication characteristics, and client support
resources. Each of these areas will play a role in analyzing a client’s
ability to receive services. As we make this analysis, it is imperative
that we take all of these areas into consideration, determine how, or if,
the environment may be modified, and whether or not a client would
be a good candidate for teletherapy.
46 Telepractice: A Clinical Guide for Speech-Language Pathologists
Physical and sensory characteristics refer to a client’s hearing
acuity, visual acuity, and manual dexterity (ASHA, n.d.a). A client
must be able to access the audio component in a videoconferencing
platform. Their hearing should be assessed if it has not been completed
recently. If we know that a client wears a hearing device (hearing aid,
cochlear implant, etc.), this will not exempt them from teletherapy
but will expose the need to look at potential modifications (Houston,
2011). Clients who have a hearing impairment and who utilize a
hearing aid or cochlear implant may be able to access the sound of a
videoconferencing platform in a couple of ways. If their aided hearing
is adequate, they may not be able to use headphones but would be able
to utilize the sound produced through the computer without addi-
tional assistance. However, it would be important to ensure that the
video feed is of good quality in order to facilitate lip-reading. Another
way for these clients to access the sound is either through a cord that is
available to hearing aid and cochlear implant users that connects their
hearing device directly to the computer. In addition, many hearing
aids and cochlear implants have Bluetooth technology that will enable
them to connect with the audio output on a computer. Determining a
client’s hearing ability is critical to successful teletherapy.
A client’s visual acuity is important to assess as SLPs need to
know what they can or cannot see and whether or not any adaptions
are available or needed (ASHA, n.d.a). It is also important to know if
a client uses glasses or contact lenses for sight, as the SLP would want
to make sure these are being used when working on the computer. If
a client has significant visual acuity difficulties, it would be important
to know what types of adaptions are available to accommodate the
client. Some individuals with significant visual impairments may use
a special screen that enlarges the print shared on the screen. The SLP
may also need to adapt the colors of the pages/screens they share
for better contrast in order for these clients to accurately see what
is presented. Some clients with visual impairments may not benefit
from any of these adaptations, so it is essential that the SLP consider
whether or not they (the SLP) can gather physical materials that these
clients may manipulate in order to have a common frame of reference
for therapy activities.
Manual dexterity refers to the ability to use one’s hands in a
coordinated manner to touch or handle objects, as well as the fine
3. Models of Service Delivery 47
motor movements that are needed to use a computer (e.g., typing,
mouse control, use of touchpad, etc.). If a client does not have ade-
quate manual dexterity, then, once again, it is important to look at
adaptions that might facilitate the use of a computer (Baker & Jacobs,
2013). It may be that a client cannot yet type but is able to use a
mouse. If that is the case, then adapting materials so that the client
can respond with only a mouse click would be beneficial and not
preclude the client from participating in teletherapy. If a client has
limited manual dexterity but is able to point to the screen, then it
would be appropriate to ensure the client has a facilitator available to
report to the SLP what the client is pointing to on the screen. As with
visual and hearing acuity, manual dexterity should be assessed prior
to beginning teletherapy to ensure that adequate adaptions are made
or the client is referred for in-person services.
The next domain will assist in determining client candidacy by
addressing cognitive, behavioral, and motivational issues that will
affect a client’s ability to participate in online sessions. Cognitive
skills give information regarding the functioning level of the client,
and that may change how we provide teletherapy, as well as affect the
nature and type of therapy materials used (ASHA, n.d.a). Oftentimes,
SLPs might assume that a cognitively low functioning client should be
precluded from teletherapy. However, this must be determined on an
individual basis. SLPs should determine whether or not the client can
follow simple directions, answer simple questions with one- or two-
word responses and, and whether or not having a skilled facilitator
will be beneficial. Again, determining possible adaptions should first
be considered before determining that a client is not appropriate for
online services.
Behavioral characteristics include the client’s ability to sit in
front of a video monitor, with their face visible within the video feed,
without too much movement, minimizing extraneous movements
(ASHA, n.d.a), as well as maintaining attention to the screen SLP
for the duration of the session. Often, parents/caregivers, teachers,
and so forth, assume that an individual (typically a child) who has
difficulty sitting or paying attention for more than a few minutes will
not be able to attend to the screen for a full session. Anecdotally, this
author has seen this assumption disproved frequently. Interviewing
the parent/caregiver prior to the start of teletherapy will reveal that a
48 Telepractice: A Clinical Guide for Speech-Language Pathologists
child, in particular, with an attention disorder will sit to play games
on the computer or to watch a movie/television show or participate
readily in other activities of daily living where they can attend for long
periods of time.
Motivation and willingness of both clients and families/caregiv-
ers are crucial to successful teletherapy services. The client should
believe that teletherapy will be interesting and will provide them with
the skills they need in order to improve their communication. Family
support/motivation is as important as the client’s motivation. When
families are skeptical or reluctant, that message can be communicated
to the client, who might then react to caregiver reluctance. Interview-
ing both the client and family prior to the start of teletherapy services
will go a long way in obtaining support for this model of service deliv-
ery. In addition, determining client interests with family members
enables the clinician to provide materials of interest to the client,
which will be inherently motivating, also goes a long way in obtaining
buy-in by families as they get to know the SLP providing services.
Without motivation and buy-in, teletherapy will be a difficult service
delivery model.
Determining client communication skills (which every SLP does)
with each client will also aid in the planning process for therapy. SLPs
should assess (formally or informally) the client’s ability to under-
stand directions and the complexity of directions they can follow.
This is particularly important with clients older than 10 or 11 years
who may not always be monitored by a family member or facilitator
sitting next to them, as the SLP may need to walk them through minor
troubleshooting during a session. Knowing the comprehension ability
will facilitate the SLPs ability to talk a client through the troubleshoot-
ing process.
Knowledge of a client’s literacy skills will assist in establishing
the level of written materials that may be utilized within the therapy
session. Using materials within the literacy levels of the client assists
with motivation as they will be more comfortable reading material
at the appropriate reading level. Understanding the family’s reading
ability is secondary but important as there are often written materials
that go home necessitating a family member’s needing to be able to
comprehend any handouts, homework, or documents.
3. Models of Service Delivery 49
Familiarity with the client’s speech intelligibility as well as the
clinician’s ability to comprehend the client is critical for the two-way
communication between client and clinician. Critically important for
both client and clinician is using good quality headsets and micro-
phones to improve the ability to hear and correct speech sound pro-
duction. The ability to accurately assess a client’s sound production
is crucial to providing effective therapy.
Cultural and linguistic variables are vitally important when treat-
ing clients in any setting, but SLPs need to be particularly cognizant
of these factors as often they are serving students outside of their
hometown or state. The cultural norms may be different in the new
state/city/town that the SLP provides services to, leading to a potential
cultural mismatch. In order to avoid this, clinicians should research
the area where the client resides to determine cultural norms, as well
as obtain information about the community that will give them insight
in order to provide culturally competent services. In addition, clinicians
need to determine if interpreters are available if needed. Further infor-
mation on cultural and linguistic variables is discussed later in this chapter.
Finally, the last domain to assess is client support services. This
includes availability of technology. Some families or school districts
may not have appropriate technology to provide teletherapy services.
If this is the case it is important to work with the family or the school
to determine if there is technology available. During the pandemic
in 2020–2021, when school districts, in particular, switched to online
services, it was discovered many students (not just students with
special needs) did not have access to any technology, including inter-
net and computers or tablets. These districts quickly reached out to
organizations and agencies to assist in obtaining internet access and
devices for clients. It is important to ascertain whether or not the client
has adequate bandwidth, a working device, and access to a facilitator
(ASHA, n.d.a).
Apps and Websites
SLPs have used apps (applications) and websites to supplement their
therapy for many years. Since the introduction of the iPad in 2010, the
50 Telepractice: A Clinical Guide for Speech-Language Pathologists
use of applications in therapy has developed. During the pandemic
(March 2020), these apps and websites have grown exponentially
(some developed by SLPs) and have become a side business for some
clinicians. There are so many choices available for online therapy—
some of them evidence-based, some very effective—but there have
been limited reviews of these websites and applications and not much
written about evaluating them in SLP literature.
On its website, ASHA (n.d.a) notes several uses for educational
apps used in treatment. Apps motivate students, collect data, record
language samples, and serve as augmentative assistive communica-
tion devices. They note that there are advantages for using apps such
as improving communication, progress monitoring, cost, and time
savings. Apps may be used for literacy, including written language
and games as rewards. However, there may be some disadvantages,
including the initial cost (e.g., devices, internet connections, cost of
training staff, etc.) and connectivity.
ASHA (n.d.a) lists questions to ask when evaluating products,
procedures, or programs. These include such questions as:
n What is the stated use of the product or program?
n What client/patient population does it apply?
n Are there publications about this product or program?
n Are outcomes clearly stated?
n Is there peer-reviewed research that supports or contradicts
the stated outcome or benefit?
n What is the professional background of the developers of the
procedure/program?
All of these questions help SLPs determine whether the app or website
would be appropriate for their particular client(s). Although these
questions give direction on how to approach the purchase or use of
apps, two studies (Edwards & Dukhovny, 2017; Heyman, 2018) noted
that SLPs typically consult colleagues (either in person or on social
media) and view online reviews as the means to assess whether an app
or website will be helpful.
This section aims to introduce a decision-making process and a
rubric for rating both apps and websites rather than recommending
3. Models of Service Delivery 51
specific apps/websites that may change over time. Although some
researchers have developed criteria for evaluating educational apps,
they are not specifically for SLP apps (Heyman, 2018). Rubrics have
also been developed for assessing apps in general (e.g., Stoyanov
et al., 2015), but none related to SLP practice. Because of the limited
research on the use of apps in clinical practice, frameworks have yet
to be developed (Heyman, 2018). One study (Rodriguez & Cumming,
2016) was found in pediatric literature that assessed the use of apps
for language intervention, specifically for receptive and expressive
language and sentence formulation. This study indicated that using
the iPad for learning was effective, but that 1:1 intervention may have
been more effective.
It has been reported that a primary reason SLPs use apps or web-
sites is for their properties of engagement and motivation (Heyman,
2018). SLPs also stated that evidence-based practice (EBP) was at
least moderately important when selecting websites or apps for use
in therapy. Many SLPs reported that they are very involved in using
iPads for treatment; that is, they do not allow the client to use the
iPad without input from the SLP who is asking questions, modeling,
and so forth, when the app or website is in use. Whereas educational
app rubrics indicate that error correction and feedback from the app
are necessary, many SLPs relied on their clinical judgment to identify
the type of correction they would use. The feedback from the app
was less critical.
Heyman (2018) developed a feature-matching checklist for SLPs
to determine the best apps for their clients. This included Theme,
Screen, Interactivity, Images, Developmental levels, and so forth.
This feature-matching checklist was developed based on the author’s
findings from her study. Heyman included not only features that the
SLPs interviewed for the study deemed necessary, but also included
features of multimedia learning gleaned from research into the use
of technology in education. Not only should SLPs consider EBP, but
they also need to understand multimedia learning to understand the
necessary pieces for intervention and identify how learning takes
place. In addition, multimedia learning concepts should be incorpo-
rated into these rubrics and used for consideration when purchasing
apps or using websites. Multimedia learning assumes that students
learn from a variety of modes. This learning method assumes that
52 Telepractice: A Clinical Guide for Speech-Language Pathologists
verbal and visual information may be processed separately. Students
have a limited processing capacity, and understanding requires
active cognitive processing both verbally and visually (Mayer &
Moreno, 2003).
In a presentation at ASHA in 2017, Moore et al. presented a
decision-making framework for service delivery that is being adapted
in the United States. While the Moore et al. framework is related spe-
cifically to school-based services, it has been adapted here for use
across most settings, ages, and disabilities. Figure 3–3 presents this
framework.
Before assessing apps for therapy, SLPs go through a decision-
making process to determine their client’s needs, area(s) of disability,
strengths, weaknesses, and the environmental factors that will affect
the client, as well as what other services that are being implemented
and/or are needed. The next step is determining what techniques
(utilizing EBP) will best meet the client’s learning needs, the learning
theory applicable to their skill level, and the intervention philosophy
that best fits the client. Once these are decided upon, SLPs then look
Figure 3–3. Service level decision-making framework services in the schools.
Based on Moore et al. (2017).
3. Models of Service Delivery 53
at any legal requirements (e.g., IEPs for schools, Health Insurance
Portability and Accountability Act [HIPAA], etc.) that will impact
therapy. These may somewhat change the mode of service delivery,
and the frequency or duration of the treatment offered.
Once the client goals are established and the SLP has decided
upon potential therapy techniques to use, the family and other indi-
viduals involved (such as school IEP teams, medical teams, other re-
lated professionals) should be consulted to obtain buy-in on goals and
direction of treatment. When this is completed, the SLP can begin
looking for appropriate materials to support the client and family goals.
Frequently this will include the use of applications and/or websites.
At this point, the SLP can now assess apps and websites to deter-
mine if they are appropriate for their particular client. Keep in mind
that if budgets are limited, it would be best to look for apps and web-
sites that can be used for more than one client or disorder and based
on the evidence being utilized for treatment procedures. Assessing
the images for age appropriateness, matching developmental and age
levels, interactivity, rewards or badges, customization, and content is
essential in determining whether an app or website will be successful
for each client. It is imperative that the SLP fully understand how
the app/website works so that there are no surprises when logging in
with a client present. Table 3–2 provides a checklist for assessing the
appropriateness of applications and websites.
In a telepractice setting, ensuring that the setup works is essen-
tial. As of this writing, when SLPs use screen-sharing applications
from an iPad or tablet to a client via a videoconferencing platform,
the client still cannot activate the app remotely. This may change over
time as the technology improves, but this aspect can be disappointing
for some clients. However, many clients can use apps in therapy if
adaptations are made. For younger clients, often, the SLP can make it
appear the client is pressing a button. In this instance, the SLP would
instruct them to move their cursor to control the button they want to
activate, then activate it themselves on their screen. For older clients,
apps can be used for improving expressive language by having the
client describe to the SLP which button or item they want the SLP to
move and where they want to move it. Additionally, clients can use
annotation tools available in many videoconferencing platforms to
mark items on the screen.
Table 3–2. Checklist for Determining Viability of Apps and Websites for Telepractice
Client Age:
Goal:
Evidence-base technique to achieve goal:
Client Factors: Age Meets Modifications Notes
Age, Functioning Lvl Appropriate EBP Needed
EBP Approach Goals
Theme (Characters
are familiar, or
approachable)
Screen: ability to add
or subtract written word
or picture
Interactivity—appropriate
for goals/level of client
Images (photo, line
drawing, cartoon, etc.)
age appropriate
Number of examples
per level (is it enough
for multiple targets
produced by client?)
Recording feature (is it
necessary or desirable
to have record feature?)
Error response—
immediate, option to try
again, etc.
Is voice of app
appropriate?
Rewards or badges—
age appropriate?
Customization (sounds
off/on, error response
adjustment, etc.)
Data tracker
54
3. Models of Service Delivery 55
In terms of websites, most are accessible by clients when screen-
shared. Again, the SLP should understand how the website operates
and ensure that it is working before therapy. Knowing which device a
client is using for their sessions is critical for the SLP to troubleshoot if
the client cannot access a website with their own device. Hundreds of
websites may be used for specific therapy activities and rewards or to
engage in interactive activities. These websites can be easily adapted
to the particular treatment plan, how the client responds, whether
verbally, using a mouse, or annotation tools.
Applications and websites can be a great addition to treating
clients for communication disorders as they engage clients and moti-
vate them. However, SLPs must use their decision-making skills and
evidence-based practice when choosing these tools. Without EBP,
apps and websites can become distracting, with clients paying more
attention to winning a game than working towards their goals.
Cultural and Linguistic Considerations forTeletherapy
As an SLP, it is imperative to match our communication skills and
competencies to explore the social contexts of our clients. These
considerations are imperative to our clients as individuals and also
as members of a global community. Many SLPs would argue that
technology has negatively impacted communication by putting
machines in between ourselves and clients. The reality is that many
client-clinician relationships today are built, facilitated, and main-
tained through interactive media, including the use of the internet,
smartphones, or text messaging (Nunez, 2009). If the profession is
concerned with cultural competence, cultural humility, and relation-
ships in this technological age, then we must be concerned with how
technology facilitates these relationships.
According to Hook et al. (2013), cultural humility can be
achieved by being “other-oriented rather than self-focused.” Cultural
humility also requires a therapist to rid themselves of self-superiority
towards another’s cultural background and experiences. By adopting
cultural humility, SLPs can be better prepared to treat diverse pop-
ulations. The selection of therapeutic activities and materials can be
56 Telepractice: A Clinical Guide for Speech-Language Pathologists
influenced by cultural humility. It can be adopted as a professional
approach to providing competent care to others that can then be
applied through technology and telepractice. As a result, even ser-
vices provided remotely can be culturally relevant and appropriate.
Figure 3–4 illustrates the intersections of cultural responsiveness as a
general guideline for speech-language pathologists.
To fully engage the whole client, speech-language pathologists
must include in their clinical practice an understanding of the client’s
goals and objectives, as well as the cultural environments in which the
client lives, interacts, and most importantly, communicates. Modern
technologies give clients more access to engaging, interactive media
to help them become connected and empowered. As Johnson (2011)
stated, clinicians, need to increase their technical skills or evolve as the
population does or become outdated in modern culture and irrele-
vant. Villagran (2011) noted an increase in interactive technology and
media tools that can be used to connect clients and clinicians asyn-
chronously. This may provide a specific benefit to members of cul-
turally and linguistically diverse groups that are marginalized or who
hold similar cultural traditions. Using interactive media with cultur-
ally diverse clients may connect clients to clinicians in ways differently
than from face-to-face. Many remote or rural populations may have
limited access to technologies. However, when accessible, these tech-
nologies may also help foster therapeutic interactions.
There are two critical constructs related to access in which SLPs
can assist their clients from culturally diverse populations, including
equitable access and equitable participation. Equity is the fair dis-
tribution of rights, resources, and responsibilities to all members of
society (Reljic et al., 2013). In contrast, access is the ability for indi-
viduals, family systems, and broader social systems to use services,
resources, information, power, and knowledge critical to community
and self-determination and healthy development at all levels (Crethar
et al., 2008). In summary, this principle is based on the belief that
society is fair-minded only when all of its members have equitable
opportunities to succeed. Culturally and linguistically diverse clients
often experience systemic barriers that decrease their ability to access
technological resources. By being aware of such barriers, SLPs and
related stakeholders in the therapeutic process can develop aware-
ness, knowledge, and abilities necessary to improve access to various
3. Models of Service Delivery 57
Figure 3–4. Intersections of cultural responsiveness.
forms of technology that improve their overall participation in
telepractice services.
In this context, participation refers to the right and ability of all
individuals to contribute to and consult on decisions that impact their
lives and other people’s lives in their systems and contexts (Crethar
et al., 2008). When clients are denied the opportunity to participate
(in-person or via telepractice), it lessens the likelihood that human
service agencies will consider the cultural, perspectives, and contextual
challenges that exemplify the lives of people these agencies purport
to serve. As SLPs work with culturally diverse clients on increasing
equitable access to technologies, they can also work towards more
equitable participation in the telepractice modality of service.
Culture and Technology
Technology has a complicated relationship with the many global cul-
tures. Technology is created and controlled by a human, and it can
58 Telepractice: A Clinical Guide for Speech-Language Pathologists
be unpredictable and used in ways very different than intended by
the inventor. For example, the internet was originally invented by the
military to decentralize military authority in the case of an attack.
Over time, and after input and changes from users of the business
sector, education, and personal users, the internet has become a global
network that lacks boundaries and jurisdictions. Without question,
technology plays a significant role in culture. The tourism industry
has grown due to technological advances in cars and aircraft. Similarly,
sporting events and the entertainment market have benefited from a
broader audience due to technological advances and connections in
broadcasting. The evidence of technology in culture is prevalent.
The term “culture” is a notoriously difficult word to define. En-
tire books, courses, if not departments, have been devoted to defin-
ing and studying it and its complexities. Understanding the cultural
factors that influence the usage and perception of culture is essen-
tial to researchers, designers, and engineers. When these factors are
understood, technological innovations, including the application of
telepractice technology in speech-language pathology, can be designed
and created that meet the needs of society to promote well-being.
Preference for Digital Communication
Digital communication is convenient. It is often how we as humans
approach communication to and with other human beings before
considering face-to-face communication. Digital communication,
including e-mail, text, and messaging platforms, offers direct expres-
sion and connections with other people. In-person dialogue can
present many problems and logistics. With the necessity of schedul-
ing, time, and distance factors, in-person communication can seem
burdensome and nonproductive compared to digital communica-
tion. Face-to-face communication has always been a genuine human
interaction. However, when digital communication achieves the same
outcome and success, it will be interesting to see how face-to-face
versus digitally based therapies are compared in the years of techno-
logical advances to come.
Wireless connectivity, known as Wi-Fi, allows a device or com-
puter (e.g., laptop, mobile phone, tablet, etc.) to connect to the inter-
net at high speed without a wired connection. The speed and access
3. Models of Service Delivery 59
of information with high-speed, wireless connections are prevalent.
Homes, offices, restaurants, business, sports, and educational areas all
seem connected and have wireless access. This availability of Wi-Fi
is further evidence of a connected society. If a place of business or
entertainment venues does not have Wi-Fi capability, then consum-
ers or patrons see the lack of access to Wi-Fi and the internet as a
disadvantage.
On a daily basis, from our time of waking until the time we sleep,
technology is present in culture and sometimes inseparable from daily
life. Technology is present in our ability to wake with digital alarms,
sleep sound machines, and even in/on our pillows and beds. Through-
out our day, we check applications for the weather before we leave
home, and use our digital devices to call Uber, or track the metro,
bus, or train. During our workday, technology is the first element
we turn on (computer), and if it is not functioning correctly or if the
internet is malfunctioning or slow, we may even choose not to work.
If we or someone in our family is in an educational setting, computers
are prevalent in the content provided (e.g., digital textbooks and
lessons) and the methods in which the content/lesson is displayed
(e.g., smartboard, Blackboard, projection system, etc.). When we
return to our homes, we may schedule or see a physician or coun-
selor via videoconferencing. We may consult YouTube for a recipe or
instructions on how to fix our vehicles. Yes, technology is everywhere.
Technology is present. It is easier to acknowledge our reliance on it
and more challenging to imagine our daily lives without it.
Technology to Address Linguistic Considerations
Clients and their caregivers must have clear information (in their
primary language) of how sessions will be delivered (either in-person,
hybrid, or remotely) and what telepractice is, and how it will work
(logistics). These elements are critical for families to comprehend.
Federal law requires that families of bilingual students and students
identified as English Language Learners (ELL) get updates from the
school in a language they understand. Learning activities must be
visually demonstrated and/or explained in the clients’ native language.
Yet, many bilingual families may not be getting adequate information
about their child’s learning activities if communication is mainly in
60 Telepractice: A Clinical Guide for Speech-Language Pathologists
English. When developing a telepractice log, a clinician can start by
identifying the client’s primary language as listed in the IEP or related
documentation. In all logs and contact information, list the primary
language next or with the client’s name. This will alert you to provid-
ing information regarding telepractice services in the client’s primary
language.
Language resources to help communicate with linguistically
diverse and bilingual clients and families are readily available. It is
imperative to identify the translation options in your professional
setting. These usually include: (1) school/district interpreters, cultural
liaisons or paraprofessionals, (2) district translation hotline, and/or
(3) translation apps. Knowing when to use what method of contact
is often the more significant challenge for clinicians. However, many
of these linguistic tools are already being utilized in professional set-
tings. Clinicians working via telepractice remotely or from a brick-
and-mortar setting should work with their related stakeholders to
identify the translation options and adapt when necessary.
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4 Assessments,
Evaluations,
and eHelpers
Introduction
When speech-language pathology services are provided to clients
remotely, using an internet connection or telepractice, the
remote speech-kanguage pathologist (SLP) may collaborate with an
additional facilitator (eHelper) who is present (in-person) with the
student. The process of developing an online relationship and culture
between the remote SLP and onsite eHelper is under-researched when
compared to the in-person model of speech-language pathology ser-
vices (Schlaak, 2018).
An eHelper is an individual who is present with the client and
assists with telepractice technology (Schlaak, 2018; Towey, 2013).
However, there is some ambiguity in the eHelper’s title in the profes-
sion of Speech-Language Pathology. When referring to the individual
assisting the SLP, the American Speech-Language-Hearing Associa-
tion (ASHA) states,
Appropriately trained individuals may be present at the
remote site to assist the client. Unless restricted by institu-
tional or state policies or regulations, the facilitator may be
a teacher’s aide, nursing assistant, student clinician, audiology
67
68 Telepractice: A Clinical Guide for Speech-Language Pathologists
assistant or speech-language pathology assistant . . . telepresenter
or other types of support personnel, interpreter, family member
or caregiver, among others . . . ” (ASHA, n.d.a)
In the K–12 school setting, the individual who monitors the
student and assists the SLP is often described as the “eHelper.” When
used in the K–12 school setting, the telepractice model includes the
remote SLP connecting to the student through an internet connec-
tion using hardware (computer) and software (videoconferencing
program). Figure 4–1 illustrates the role of the eHelper in telepractice.
When providing services via telepractice, and when an eHelper
is present, the SLP is responsible for directing the session. As outlined
earlier, ASHA provides some general guidelines and recommenda-
tions that eHelpers “may be present at the remote site to assist the
client” (ASHA, n.d.a). Considering the remote location and separation
between the SLP and the eHelper, there are still very few guidelines
for the professional background or role of an eHelper. Furthermore,
the role of the eHelper during telepractice sessions can also vary
depending on the type of services provided (e.g., articulation therapy,
language therapy). There was a distinctive list of responsibilities of
the telepractice facilitator listed by ASHA (2010), which identified
the general responsibilities and functions of telepractice eHelpers;
however, this professional document was rescinded (ASHA, 2010) and
replaced with the “Telepractice Portal” (ASHA, n.d.a) which does not
include specific roles or responsibilities of the eHelper. According to
Alvares (2013), the eHelper activities outlined in the now rescinded
document included the following: (a) escorting clients or students to
and from sessions, (b) establishing and troubleshooting the telepractice
connection, (c) setting up therapy materials, (d) positioning the client
at the direction of the SLP, (e) remaining with the client or student
during sessions, (f ) assisting with behavior management as needed,
(g) communicating with on-site staff or teachers about scheduling, and
(h) in some instances serving as the interpreter (Alvares, 2013).
When the telepractice model of service delivery is utilized, a
remote SLP is connected to the student using the internet, videocon-
ferencing technology, hardware, and software. Due to the physical
distance between SLP and the student, an eHelper may be present
69
Figure 4–1. The role of the eHelper in telepractice.
70 Telepractice: A Clinical Guide for Speech-Language Pathologists
with the student to assist with telepractice technology. A key element
of telepractice is the need for the SLP and eHelper to work together
in an online environment while located in separate geographic loca-
tions to deliver telepractice services. SLPs often work with students
that may have difficulty accessing services at the remote site due to
age (young children), cognitive, and/or physical limitations (Black
et al., 2015). The eHelper could be essential to the interpersonal con-
nections between the SLP and student; however, the culture of this
relationship has not been explored in the body of existing research in
speech-language pathology.
The eHelper is the physical and present element that facilitates
the connection between the SLP and the student. In telepractice ses-
sions, the SLP may rarely, if ever, physically enter the school building
or meet the student(s), unlike the traditional in-person model of
services. The eHelper may interact with students, teachers, and staff
on a daily basis and become the “face” of the telepractice program
(Alvares, 2013). To understand the current role of eHelpers in online
speech-language pathology, it is necessary to understand the tech-
nological advancements that created the environment in which they
work. These advancements include the availability of wireless net-
working technology ((Wi-Fi)) internet capabilities, broadband inter-
net, and high-speed connections that have been integral in providing
broader access for schools and clients to provide online learning and
therapeutic opportunities. The use of videoconferencing tools as a
medium to connect individuals in separate locations for meetings,
learning, and therapeutic opportunities has brought new and inno-
vative ways for allied health and special education professionals like
SLPs to connect to their clients. The use of secure, encrypted, Health
Insurance Portability and Accountability Act (HIPAA) compliant
videoconferencing platforms has been widely adopted by related pro-
fessions, including audiology, occupational therapy, physical therapy,
and school counselors. As a result, these professions have also adopted
terms to define the delivery of services online, including teleaudiol-
ogy, telerehabilitation, telehealth, and teletherapy. These technolog-
ical advancements, combined with an increased cultural acceptance
of technology in the workplace, have all contributed to the use of
telepractice to provide speech-language services.
4. Assessments, Evaluations, and eHelpers 71
Per ASHA, a facilitator is an appropriately trained individual who
may be present at the remote site to assist the client (ASHA, n.d.a.)
Unless restricted by state-specific policies or licensure regulations,
the facilitator may be from one of several backgrounds, including
a paraprofessional, teacher’s aide, student clinician, speech-language
pathology assistant, interpreter, family member, or school volunteer,
among others (ASHA, n.d.a).
When working with an eHelper, the SLP must be aware of appli-
cable state policies and regulations regarding the use of facilitators
and adhere to any specific state regulations on their involvement in
sessions (ASHA, n.d.a). The type of facilitator required at the remote
site may vary depending on the type of service being provided. It is
important to note that, at all times, it is the responsibility of the SLP to
direct the session and ensure that the facilitator is adequately trained
to assist. According to ASHA (n.d.a), adequate training includes
“knowledge of and sensitivity to clients’ cultural and linguistic dif-
ferences, as well as how such differences may influence participation
in telepractice.” Although the duration and frequency of the training
can vary, in many instances, the eHelper may perform many of the
same duties as an in-person paraprofessional (Table 4–1).
Research and Evidence-Based Practice
Alvares (2013) discussed the use of facilitators (eHelpers) when
speech-language pathology telepractice services are provided in
public school settings. The author emphasizes that eHelpers have
several key responsibilities, including escorting students, estab-
lishing and maintaining internet connections, setting up materials,
and scheduling. The author describes the many specific challenges
that are presented to the SLP and the facilitator’s social context
in the online environment, including communication challenges
with the SLPs, onsite teachers, and staff. An integral statement made
by the author addressed the crucial role of the eHelper, stating, “the
eHelper becomes the face of the telepractice program. It is possible
that the SLP rarely, if ever, steps foot in the building.” This statement
72 Telepractice: A Clinical Guide for Speech-Language Pathologists
Table 4–1. Comparison of In-Person Paraprofessional and eHelper
In-Person
Paraprofessional eHelper
Troubleshoots technical Yes Yes
issues
Escorts students to and Yes Yes
from session
Sets up session materials Yes Yes
Positions client Yes Yes
Assists with behavioral Yes Yes
management
Communicates with on-site Yes Yes
personnel
Serves as interpreter If trained/proficient If trained/proficient
introduces one of the recurrent themes in eHelper research and schol-
arly discussions.
Grogan-Johnson et al. (2013) studied the delivery of speech-
pathology services in school with an eHelper (assistant) working with
the SLP. This study investigated the progress made by 14 children
ages 6 through 10 years, diagnosed with speech-sound disorders.
As part of the study, the authors used research assistants to serve as
eHelpers. These assistants were assigned critical tasks to encourage
interpersonal relationships in the telepractice environment, including
escorting the children and their parents to and from the therapy room
where the study took place. Once in the therapy room, the assistant
remained in the room for the duration of the session in the event
they were needed to assist with any technical issues that could arise.
According to the authors, the assistants were needed to adjust the
cameras and troubleshoot technology issues. In a discussion of results,
the authors noted that the assistants were required to arrive before the
start of all the telepractice sessions to perform several tasks, includ-
ing setting up the hardware and equipment (computers, headset) and
4. Assessments, Evaluations, and eHelpers 73
software (internet connection). The assistants were often needed to
troubleshoot activities, including resolving any internet connection
issues and adjusting headsets to fit the child properly. The research-
ers provided assistant training before the start of the study for each
assistant utilized in the study.
Overby (2018) addressed several issues regarding eHelpers in a
study of stakeholders (e.g., SLPs and school faculty) perspectives on
telepractice. The first area addressed was the ambiguity and variations
in nomenclature for the facilitator. When identifying the individual
who assists in telepractice, the author states:
An eHelper, therapy facilitator, or therapy assistant is an indi-
vidual trained to assist the client/patient at the remote site
(ASHA n.d.a). Assistance may include, but is not limited to,
escorting the client to and from the session, scheduling and
setting up the session, assisting with behavior management,
and possibly serving as an interpreter. (p. 108)
The author restated the ambiguity between terms when dis-
cussing the results of the study, “Within the theme of telepractice
clinical skills, all three groups [of participants] described the same
five subthemes [including] managing eHelpers (‘therapy facilitator’ or
‘therapy assistant’)” (p. 110). Although the authors provided several
different terms, the most often used term was eHelper.
Beyond determining the best term between facilitator, eHelper,
and assistant, Overby (2018) identified several themes that included
the results of the eHelper. These themes include managing clinical
skills, the overall effectiveness of telepractice services, and facilita-
tor training issues. Within the theme of managing clinical skills, the
SLP participants included in the study felt that managing eHelpers
was most important, with 33.3% of SLPs providing this response.
Management of eHelpers was ranked higher than the selection and
preparation of materials, which was the second most crucial clin-
ical skill, with 22% of the SLP participants in the agreement. The
SLPs participants also responded as to the best fit for the role of an
eHelper, offering suggestions of a school volunteer, teacher, or the
client’s family member.
74 Telepractice: A Clinical Guide for Speech-Language Pathologists
In the discussion of the results, Overby (2018) proposed that
the eHelper could be needed to escort the client to and from the
session and understand basic privacy and security measures. Within
this discussion, participants agreed that the SLP would need a strong
working relationship with the eHelper to assist with behavioral modi-
fication and monitor the student’s attention. Although the SLPs agreed
on the importance of the eHelper, all three stakeholder groups com-
mented that telepractice requires the SLP to collaborate with others
to ensure the client arrives on time for the session, follows instruc-
tions during therapy, or practices newly learned skills outside of the
therapy context. Finally, the SLP participants felt managing eHelpers
was high in importance because of the “frequency with which they
[SLPs] engage with eHelpers when providing telepractice to children
in schools” (Overby, 2018, p. 110). In summary, Overby outlined
several salient points concerning the use of eHelpers in speech-lan-
guage pathology. The researcher found the management and the
incorporation of eHelpers during sessions was an integral element
to the program’s success. Those surveyed reported that telepractice
requires the SLP to collaborate with an eHelper to ensure that the
client arrives on time for the session, follows instructions during
therapy, and carries over newly learned skills outside of the therapy
context. Furthermore, Overby (2018) found that SLPs reported that
students need a strong working relationship with the eHelper to
ensure a positive telepractice environment.
Gabel et al. (2013) studied the effectiveness of telepractice ser-
vices across several school districts. As part of the study, the authors
cited the need for telepractice assistants to ensure the proper delivery
of services. Within the study, each school employed a staff member
to serve as a telepractice assistant who met the district’s requirements
for an instructional aide. The authors described how each telepractice
assistant was present during all teletherapy sessions to troubleshoot
any equipment or technology malfunctions, provide an adult presence
in the therapy room, and escort the students to and from therapy
sessions. The eHelper did not participate in the therapy session in
any way or provide intervention services. The researcher provided
training for each telepractice assistant on the use of the software and
4. Assessments, Evaluations, and eHelpers 75
equipment, responsibilities related to scheduling, and all guidelines
related to confidentiality. The telepractice assistant was also respon-
sible for equipment setup before sessions and storage after sessions.
The researchers discussed the presence of the telepractice assistants
at each session for all 71 participants, demonstrating the importance
of their role in a school telepractice program.
Fairweather et al. (2017) investigated the use of telepractice
assistants in rural and remote K–12 schools. A total of six telepractice
assistants were included in the study. The assistants were asked to
describe the barriers and strengths of the telepractice program using
semi-structured interviews. The authors described therapy assistants
as having the ability to improve access to telepractice services and
other tasks to contribute to a successful telepractice program. The
therapy assistants included in the study were described as:
. . . typically employed, trained, and supported to work under
the direction of an Allied Health Professional (AHP). While
the position of therapy assistant is often a paid position for
people with the appropriate certification, in this study, the
term is used to describe the role of existing staff in schools
and unpaid volunteers when fulfilling therapy assistant
functions in allied health professional-directed interventions
(Fairweather et al., 2017, p. 2).
In the discussion by Fairweather et al. (2017), the researchers
made several salient points about the importance of therapy assis-
tants, including their significance in the school setting and the need
for training and clarification about their role(s). The study results
indicated that therapy assistants believed that they were underutilized
by the SLPs as sources of valuable information and ideas on improv-
ing the interaction between the SLP and the student. Furthermore, the
therapy assistants identified collaboration and communication with
teachers as areas of weakness for telepractice and an area where SLP
and telepractice assistant teamwork could improve. The SLP partici-
pants strongly valued building relationships via telepractice, including
their relationships with the therapy assistants.
76 Telepractice: A Clinical Guide for Speech-Language Pathologists
Schlaak (2018) addressed the much-needed area of professional
competencies for eHelpers. The researcher conducted a survey that
proposed a set of competencies necessary for eHelpers in speech-
language pathology during telepractice services. Results indicated
four competencies or themes for eHelpers including, (1) telepractice
sessions (setting up technology, audio, video), (2) technology-specific
(problem-solves technical issues), (3) interpersonal (interacts with
students and other professionals), and (4) policy and procedures
(school policies, confidentiality, and privacy). As a result of the study,
the researcher was able to create a set of competencies for school-
based eHelpers and contribute to a much-needed knowledge base in
speech-language pathology.
Each of the outlined research studies, discussions, and materials
presented in this section contribute to the much-needed discussion
on the role of the eHelper in speech-language pathology. Issues related
to their use, role, and implementation are outlined. When looking
at the body of research as a whole, the variation in terminology and
title of the eHelper is a glaring issue that binds each study. Table 4–2
demonstrates the terminology used to describe the eHelper across
the literature.
Table 4–2. Variations in Nomenclature
Assistant eHelper Facilitator Other
X X
Alvares (2013) X X
ASHA (n.d.a) X
X
Fairweather et al. X
(2016)
Gabel et al. (2013) X
Grogan-Johnson X
et al. (2013)
Overby (2018) X X
Schlaak (2018) X X
4. Assessments, Evaluations, and eHelpers 77
Collaboration
eHelpers are essential to forging a successful relationship with onsite
personnel and are essential components of a successful telepractice
program (Fairweather et al., 2016). Furthermore, the working rela-
tionship between the remote SLP and on-site personnel can be influ-
enced by the eHelpers. This relationship and more importantly the
communication between the SLP and onsite personnel is an essential
component of a successful telepractice program, and eHelpers can
be essential to forging these positive relationships. The eHelper is
an essential, onsite asset that can forge interpersonal connections
between the SLP and those that come in contact with the student,
including caregivers/parents, and general and special educators.
The eHelpers’ interactions with the SLP during telepractice
sessions must be observed and documented to understand this role.
When armed with information regarding the eHelpers’ role, the col-
lective stakeholders (SLPs, school administrators, parents) are better
equipped to understand telepractice as a modality of service. Ques-
tions could arise as to if the eHelper is an active or passive participant
in telepractice sessions, and observation could provide answers to
such questions. For example, if the eHelper assumes an active role
and is involved in the provision of services under the supervision
of a licensed SLP (i.e., provides and plans additional on-site inter-
ventions), then could their role be considered within the scope of a
Speech-Language Pathology Assistant (SLP-A)? If the person provid-
ing therapy is acting as an SLP-A, then have the required credentials
and requirements been obtained to practice in the state where ser-
vices are rendered legally? Likewise, the SLP providing services must
adhere to the supervisory guidelines mandated by the state in which
the services are being provided. If the person providing therapy is,
indeed, acting as an SLP-A, then the required credentials and require-
ments must be obtained to practice in the state where services are
rendered legally. At a time when telepractice services are well under
way, and have been, as such for decades, these significant issues need
to be addressed.
78 Telepractice: A Clinical Guide for Speech-Language Pathologists
Managing Technology
An eHelper may also be essential in order to connect the remote
SLP with onsite technical support. When establishing a telepractice
program, onsite Information Technology (IT) support is required to
establish the hardware, software, and internet connections. Given
the IT professional’s knowledge of the technical infrastructure and
usage at an on-site location, they are the first-line contact for school
staff to discuss and troubleshoot technical issues. Within this context,
establishing communication and collaboration between the off-site
SLP and on-site eHelpers and IT personnel will ease the technology
selection process and help with troubleshooting when issues arise
(Juenger, 2009). The on-site IT personnel should be made aware of the
times and dates that telepractice services are being provided and may
require IT support, and the eHelper can be of assistance, given their
involvement in the telepractice program. Traditionally, the on-site IT
personnel are responsible for facilitating ongoing quality assessments,
managing initial and ongoing training of personnel, and ensuring
that providers are kept abreast of advancements and best practices
in telepractice methodologies. In this role, they can be an important
collaborator of the eHelper.
To ensure successful telepractice sessions, the remote SLP has
several responsibilities to ensure successful implementation and use
of telepractice. According to Boisvert (2012), these responsibilities
include: (1) an overview of the feasibility, standards, benefits, and
limitations of telepractice; (2) the necessity to obtain outcome data
using standardized procedures and processes; (3) evidence of profes-
sional certification and licensure; (4) regularly scheduled meetings;
(5) intervention planning; (6) data collection and documentation;
(7) data security and privacy; (8) clinical techniques and behavioral
management strategies; (9) a review of assessment and screening
protocols for use with telepractice;
(10) consultation with parents/
guardians, general and special educators, and other personnel (i.e.,
specialists, physicians, clinicians); (11) resources and materials to be
used for telepractice; and (12) the critical collaboration with on-site
personnel (Boisvert, 2012). When considering these and the many
4. Assessments, Evaluations, and eHelpers 79
other tasks that must be accomplished by the SLP, the need to utilize
and identify the role of the eHelper is evident and essential.
Parent Coaching
Parents, guardians, spouses, caregivers, and family members are
crucial to the success of telepractice sessions and the success of clients.
Empowering the parents of students, or the caregivers/spouses of
adult clients, helps to ensure that telepractice is an effective means
of increasing access to high-quality services that meet the needs of
the client. Over the years, a growing number of studies have investi-
gated the parent training and coaching programs that can be used via
telepractice (Snodgrass et al., 2017). The following section will outline
these programs and provide guidelines for success (Figure 4–2).
1. Identify the target skill
2. Identify the target strategy
3. Teach the parent/caregiver
4. Coach the parent/caregiver to mastery
a. Observe the parent/caregiver
b. Provide time/space for reflection and feedback
c. Repeat Steps 1–3
Parent coaching builds a cooperative and collaborative relation-
ship between the coach—remote/online SLP—and the on-site parent
or professional through empowerment. The partnership between a
parent and the SLP can create a bond during the remote and online
therapeutic process (Turnbull & Turnbull, 2001). Together they deter-
mine a specific, evidence-based coaching strategy to be practiced in
each session. The SLP demonstrates the coaching strategy and applies
it during the intervention session, and the parent then practices the
strategy and receives feedback from the SLP through videoconfer-
encing. For example, the child may delete the final /s/ from words,
so the SLP may suggest checking the client’s auditory detection of
80
Figure 4–2. A model for eHelper/facilitator coaching via telepractice. Adapted from Snodgrass et al. (2017).
4. Assessments, Evaluations, and eHelpers 81
the /s/ sound. Professionals and parents collaborate to help the client
succeed. This interdependence is critical for telepractice success
because the professional or parent working directly with the child
keeps the SLP apprised of quality indicators and incorporates cultural
and linguistic norms appropriate for the client’s natural environment.
Training
Although it is agreed that eHelpers should be trained, the scope,
length, and content of the training are largely undefined. Indeed, the
term eHelper is not a universally accepted title for the individual who
assists the SLP in a telepractice setting, and there are many strides to
be made in the acceptance of a single term. As outlined earlier in this
chapter, the American Speech-Language-Hearing Association (n.d.a)
provided the following guidelines for a facilitator in telepractice:
Appropriately trained individuals may be present at the remote
site to assist the client. Unless restricted by institutional or
state policies or regulations, the facilitator may be a teacher’s
aide, nursing assistant, client clinician, audiology assistant or
speech-language pathology assistant, teleaudiology clinician
technician, telepresenter, or other type of support personnel,
interpreter, family member, or caregiver, among others. (para. 3)
When attempting to define the role of the eHelper/facilitator in
speech-language pathology services, referencing other professions
may provide the insight needed to move toward a clear title that can
be readily documented in future studies and literature. One such ref-
erence could be the American Telemedicine Association (ATA). The
American Telemedicine Association is a coalition and partnership
of over 400 organizations dedicated to advocating for the adoption
of telehealth and providing education and resources to support the
emerging telehealth industry.
In 2017, ATA voted for the accreditation of a telehealth training
program that offers a Telehealth Facilitator certificate, overseen by
Thomas Jefferson University in Pennsylvania. Successful completion
82 Telepractice: A Clinical Guide for Speech-Language Pathologists
of the five-week program culminates in the individual earning a Tele-
health Facilitator certificate. The holder of the Telehealth Facilitator
certificate is then recognized as an individual who will:
1. Facilitate conversation between patient and provider,
2. Initiate the encounter, manage the interface between doctor and
patient and address all technical challenges that may arise, and
3. Ensure a sound and successful, professional medico-legal,
culturally sensitive experience for the patient (Thomas Jefferson
University, n.d.).
Along with clearly defined roles and responsibilities as outlined
above, the title of Telehealth Facilitator is accepted within the body
of professionals represented by ATA. The Telehealth Facilitator role
outlined by ATA could be a model used by ASHA and accepted by
SLPs for eHelpers. There is a need for agreement on the title of the
eHelper/facilitator across the literature of speech-language pathology.
The eHelper is a prominent contributor in telepractice and an asset to
the SLP, as demonstrated in this study. However, without consistent
nomenclature, professionals are left to determine the many facets
of the eHelper’s role, as well as their role in telepractice services. If
accepted broadly and utilized consistently, the eHelper’s role could
be another step in best practices in telepractice and the field of
speech-language pathology.
Assessments and Evaluations
In the past 5 to 10 years, an increasing number of speech and
language-focused product companies have moved toward digital
and electronic versions of tests and test materials. Some of these
companies also offer electronic scoring systems. The proliferation
of online and digital assessments has allowed SLPs to provide eval-
uations online in a videoconferencing platform. Some assessments
have been validated for online use, allowing SLPs to feel confident in
administering them in an online format. Research of online assess-
4. Assessments, Evaluations, and eHelpers 83
ments have been published that supports assessments via telepractice
(e.g., Blaiser, 2016; Hall et al., 2013; Raatz et al., 2021; Sutherland
et al., 2016). Although formally assessing clients via telepractice may
be daunting, it can be completed successfully with the right tools,
the appropriate environmental considerations, good communication
between the clinician, the client, and stakeholders, the appropriate
technology, preparation, considerations for bilingual clients, and
ethics and confidentiality (Hodge et al., 2019; Wood et al., 2021).
Early in the history of telepractice, both technology and digital
assessments were lacking to evaluate clients effectively via telepractice.
Videoconferencing platforms did not have screen-sharing capabil-
ity nor annotation tools. Document sharing cameras were also very
limited and carried a high price tag. Technology began catching up
with the advent of the ELMO in 1988. ELMO technology was one of
the first document-sharing cameras. It allows the user to screen share
documents, books, and other paper-based materials with a client.
This technology was first used in schools and businesses to project
information from a computer onto a large screen. This allowed stu-
dents in a classroom or people attending a business meeting to see
information projected on a screen. The technology has further devel-
oped into document sharing cameras that are now much smaller, fit
on a desk, and can be connected to a desktop or laptop computer. The
price has decreased, and good quality document cameras are avail-
able for fifty dollars ($50.00) or less. The document sharing cameras
allow SLPs to share the picture book of a test with a client while in
a videoconferencing platform. Many SLPs have learned to use their
smartphones or tablets as a substitute for a document-sharing camera
as an alternative to purchasing one separately.
One of the first digitally available assessments was from Pearson
Assessments, and included the Q-Interactive system. This allowed
a clinician with two iPads to administer Pearson Assessments elec-
tronically, but only in person. With this setup, the client’s iPad had
the picture book portion of the assessment, and the SLP’s iPad
had the pictures and the instructions given to the client. Pearson also
developed the Q-Global system, which permits clinicians to access
the picture books electronically, and was initially for in-person eval-
uations with the picture book shown on a computer screen. During
the pandemic, Pearson (2020) authorized SLPs to use digital picture
84 Telepractice: A Clinical Guide for Speech-Language Pathologists
books via a videoconferencing platform. Since then, several other
companies, including WPS and Brooks Publishing, among others,
have produced electronic or digital versions to be used within a
telepractice setting. These innovations have made it easier to use
formal assessments while engaged in telepractice.
There have been differences of opinion as to whether assess-
ments should be renormed for use in telepractice. To date, most
publishers have validated their digital versions of tests for use in the
telepractice service delivery mode. Several researchers have published
studies that indicate telepractice is an appropriate model for adminis-
tering specific assessments (e.g., Waite et al., 2010; Sutherland et al.,
2017) to obtain accurate information regarding a client’s communi-
cation abilities. It is important to note that there is a need for further
research on performing assessments online. The current studies are
limited in comparing different teleconferencing platforms, how that
might influence the assessment, and how validating modified instruc-
tions are sometimes required for telepractice due to the nature of
the subtest. Research on preschool assessment is very limited at this
time. Research is needed to look at the difference between assessing
a client in their home as opposed to a school, clinic, or other setting,
to determine whether testing outcomes vary depending on the site
the client is in.
As SLPs also use other methods of data collection, such as
language sampling and observation for an evaluation, these need to
be adapted for use in a telepractice environment. The research on how
to obtain language samples and observations and whether telepractice
is a valid method to perform these tasks is needed as well. Further
details are to be provided later in this chapter on the current best prac-
tices to obtain language samples and perform observations, which are
helpful in gaining information about how clients use language in less
formal settings.
Setup for Successful Administration of Assessments
One of the first priorities before an assessment is completed is to
ensure the confidentiality, comfort, privacy, and safety (ASHA, n.d.a)
4. Assessments, Evaluations, and eHelpers 85
of the client. Prior to beginning the assessment, contact with the client
and family/caregivers will be instrumental in the successful admin-
istration of tests. The room location, lighting, and furniture should
optimize the client’s ability to readily participate, as well as the reduc-
tion of background noise and visual distractions. The location where
the client receives services will depend on whether the telepractice
services are being provided to a school setting, in the home, or a
clinic. The principles for setting up an appropriate environment are
similar across these settings, with a few minor adjustments based on
the site. These adjustments will be noted throughout this section.
The room in which the client (and clinician) sits to receive
telepractice services should be quiet, with a door that can be shut
during the assessment for privacy and confidentiality. This will ensure
that an unauthorized individual will not enter the room without the
knowledge of the clinician or client. The room should be in a quiet
spot where outside noises (e.g., cars, construction sites, playground
noise, etc.) or inside noise (e.g., a choir practice, noisy classroom,
television, or radio) will not disrupt or disturb the assessment session.
Sometimes it is difficult to predict outside noises, so it is important
to check in with caregivers or family members regarding potential
auditory distractions that may ensue, and to be prepared ahead of
time and allow planning for potential disruptive noises. Families or
caregivers can be enlisted to ensure that other people in the home will
not disturb the evaluation session, and that family pets are quiet and
out of sight. Regardless of the setting, an adult should be present to
troubleshoot or assist the client if the client themselves cannot do it on
their own. For most children, the presence and support of a responsi-
ble adult is vital to provide troubleshooting and reinforcement.
Lighting in the room should facilitate the clinician and client’s
ability to see each other in full light. When the light comes from
behind the client, it will make it difficult to see the face of the indi-
vidual (whether it is a client or clinician); therefore, the best lighting
is either overhead or a lamp to the side of the individual. There are
also “halo” lights that are small and can be clipped to a computer for
betting lighting. An open window that faces the sun will also affect
how that individual is seen in a videoconferencing platform, so it is
important to experiment a bit with the light in order to determine
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