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Determining Who’s Appropriate for Telepractice: Working with Kids with Cognitive Impairments

Screen shot of an online therapy session

“Joey” is a five-year old student with Down syndrome, who is nonverbal and primarily uses signing with some vocalizations to communicate. You are the teletherapist assigned to his school site and on the first day of therapy, the school staff voices major concerns about Joey participating in speech and language services via telepractice. They are particularly concerned about losing valuable time in his development to make a difference in his speech and language growth.

How do you proceed?

Telepractice continues to be a relatively new delivery mode for special education services. There is a growing body of evidence to support that telepractice services do make a significant impact in the lives of many individuals. Despite the research and data, there are many skeptics who do not want their student or their child to be part of the what they view as an experimental process. They would much rather stick to the tried and true method of in-person, face-to-face therapy.

There is also an underlying belief that there is an impersonal touch to telepractice due to the clinician not physically being in the building and hence able to interact with the school staff through common activities every day. It is hard for some to believe that a therapist who is connecting with a student through the computer could establish a relationship and/or rapport with a student he/she has never met in person. However, when you consider how we communicate with each other every day, the notion of talking or connecting over your mobile device or videoconferencing is not at all unusual. Being able to see and hear the clinician through live, interactive sessions allows the professional to connect with the client and develop relationships.

In my years at PresenceLearning, many clinicians, parents, school staff, and even students have shared stories about the strong relationships they’ve developed and the close collaboration online clinicians have with school staff. Our videos tell many of these stories, but this note from a parent whose son graduated from speech services particularly shows that online relationships are just as strong as those in person.

Saying goodbye was sad for both A. and me. I, too, had a few tears. You have become a part of our family and such a loving and caring friend to A. You gave so much to him, and he worked to use what he learned throughout the week. When you come into our home [ed.: A. received online services at home through his school] two times every week, well, it hurts when the year ends. We love you and thank you for being a part of our family this year. I know A. will remember you.

It is important to give everyone an equal opportunity when it comes to teletherapy. Frequently it is the students deemed as not being a good fit for teletherapy that end up surprising us the most by how well they respond to this mode of delivery. In order to set up a student for success, it is important to plan for some potential pitfalls, and give every student at least 4-6 sessions of trial therapy with some well-thought out strategies in place.

Let’s get back to our client, Joey. After we review his records, meet him virtually, and listen to the concerns of the school site, what should we do next? The following strategies can help to determine whether online therapy is an option for Joey, but are also best practices for working with all students.

  1. Ensure that there is a dedicated facilitator that will help with cuing and prompting.
  2. Train the aide so that they are cuing when you are prompting them to cue. Explain the importance of cuing hierarchy and how every prompt is purposeful, whether it is verbal, visual, and/or tactile.
  3. Enhance visual acuity. Make sure to make your image and any therapy materials larger on the screen. Many students with complex therapeutic needs including visual and attention problems will benefit from enlarged images.
  4. Plan the therapy around the student’s needs. Make sure to use digital flashcard p-5 bg-lightest mb-3s and videos of subject matters that interest the student. If the student loves Elmo, be sure to use these opportunities to initiate verbalizations and expand their sentences. A student with sensory needs may prefer to hear the session directly through the computer speaker rather than wear a headset.
  5. Parents are the best therapists. Parents are an integral part of the therapy program. If a parent regularly participates in your sessions, be sure to set aside some time to consult with them on the importance of letting their child work directly with you on the computer. Being the primary educators of their children, they will benefit from some training on how a cueing hierarchy would work with their child. Let them observe sessions so they can learn to help their child generalize skills outside of the therapy session.

It is strongly recommended that all students be given a fair chance at the onset of therapy to receive services online, especially when the alternative would be no therapy. However, while most students are a fit for teletherapy, it is true that some truly aren’t. For example, a student who is not a good candidate may be someone who has complex therapeutic needs, needs hands-on guidance, and has significant hearing, vision, and cognitive deficits.

The protocol for PresenceLearning therapists is to employ a trial period of therapy using many different strategies. When the student is ultimately not a fit, they alert the PresenceLearning lead clinician and Senior Clinical Consultant assigned to the school site and work closely on each case referred for in-person service delivery when the student is not an appropriate telepractice candidate.

Karin H. Koukeyan, MS, CCC-SLP, is a Senior Clinical Consultant with PresenceLearning.

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