Thursday, November 7, 2013

Teletherapy with a Language Focus

Language has always been my strongest area of interest. It takes on different forms from the spoken word to body language.  It infuses every part of our daily lives; starting from the moment we arise and say, “Good morning,” to the dreams we have while asleep. One of the most intriguing characteristics about language, I find, is that it can be stimulated anywhere and at almost any time!  The computer is a wonderful piece of equipment that allows us to travel anywhere and research unfathomable and infinite topics!  People are drawn to computers to communicate whether it is through Facebook, Twitter, LinkedIn, etc.  Providing language therapy via computer allows people to utilize something they normally interact with on a daily basis.  What better way to contact others and address language goals than through a medium that everyone will need to employ and be comfortable with at some point in his/her student- and adult- life.  A professor once told me, “A skilled Speech/Language Pathologist should be able to create and provide a therapy session armed with nothing more than a pencil.”  Is this true of teletherapy?  Could a computer be a substitute for a pencil?  What are some ways to incorporate materials or techniques from my onsite experience into the teletherapy I provide?

What types of language goals can be addressed using teletherapy?  I’d say almost any and/or all goals.  Let’s break down the different areas of language that could be listed on an IEP and consider how to address them through the provision of teletherapy. 

Vocabulary is one area that tends to be a focus of therapy for many clients.  One option would be to use any vocabulary materials you may already own (from working onsite) with the help of a document camera.  You have the choice of either scanning the document or taking a picture of the page with the document camera both resulting in a copy of the page on your computer to pull up and use with your web-based, video conferencing platform.  Using the platform’s tools, you can interact with the vocabulary page in numerous ways such as coloring, circling, crossing out, and/or highlighting the information.  If you prefer to introduce vocabulary using literature, you can read the story to your client using the document camera presenting the pages of the book to your client as you read it aloud.  If there are specific vocabulary words, pictures, or both in the story that you want to focus on, you can scan in a page that contains that information, call it up onto your desktop using the “Paint” program, crop the page down to the section you want, and then cut/paste it into a new document, PowerPoint slide, etc.  By creating a place to type next to or under the picture you pasted, you could ask the client to type the label of the item, use it in a sentence, etc.  This is just one way to emphasize vocabulary.

What about concepts?  Temporal, spatial, qualitative, and/or quantitative concepts can be addressed with your own, hard-copy materials using the document camera, or you could create a PowerPoint presentation.  I personally enjoy creating my own PowerPoint slides requesting the client to identify the picture depicting the concept or by having the client click on the appropriate picture and moving it to the correct spot on the page following my directions (e.g., Can you put the box next to the blue car? See the bowl with apples in it?  There are only 2 apples in it.  Could make the bowl “full” of apples?). The more interactive the material, the more engaged your client will be and the better he or she will retain the information.  Even while working on quantitative concepts, developing PowerPoint slides makes creating your own materials a breeze!  I find PowerPoint (PPT) easier to work with than a WORD document.  The interactive PPT document is user-friendly on a SMARTBoard too if the classroom teacher would like to carryover the lesson into his/her room!  I’ve created short, interactive lessons using PPT for some math concepts such as “greater than” and “less than” to help provide a visual component to aid comprehension as well as motivating students to stay on task.

There is also inexpensive software available through LinguiSystems, SuperDuper Publications, Thinking Publications, and Lakeshore (to name a few).  Any software program you can use on a computer or interactive whiteboard can be used for teletherapy (depending on the type of web-based, video conferencing platform you are using, of course).  If the platform allows you to switch control from the clinician to the client, the client will have the ability to interact with the software even though it is loaded and running on your, the clinician’s, computer!  Many of these programs, especially from Lakeshore, are provided in a “game” format which my students really enjoy.  I will also use the software for positive reinforcement.  If my student completes the tasks requested, I will typically save some time at the end of the session to play one of the software games.  Thus, the client is really continuing to work but he or she views it as playing a game after completing his/her work.   LinguiSystem has CD programs for their Autism and PDD population.  This software is highly motivating for my students whether they have been diagnosed or display symptomology of Autism & PDD or not.  “Buddy Bear” and/or “Bonnie Bunny” CD's work well for addressing concepts, vocabulary, sequencing, and predicting.  There are free websites available online for students to use to reinforce a goal or for positive reinforcement as well.  I will list a few at the end of this article for you to consider.

In terms of grammar skills, I enjoy creating my own materials to mix in with the interactive software I’ve purchased.  The software tends to be a bit “dry,” so, to liven up the session, I’ll look for videos demonstrating the tense form, adjective, noun, etc. that we’re working on.  CAUTION:  YOU SHOULD WATCH THE COMPLETE VIDEO BEFORE SHOWING IT to your clients to be sure it is completely appropriate.  Watch the commercials along the sidebar (if the site displays a loop of advertisements) because inappropriate advertisements can suddenly appear.  Videos from are usually safe, but I still view them ahead of time making sure that the video is culturally appropriate.  “Pixar’s Shorties” DVD is an excellent source for short, cute video stories to practice grammatical forms.  For example, you could teach “past tense” verb forms and what that means.  Then, supplement your lesson with, “For The Birds” Pixar Shortie, and when it is finished, you could discuss the things that happened in the video.  The more areas of language you can incorporate into your lesson or that you can practice simultaneously (once your student has reached this point in the therapy process), the more relevant the information will seem which will aid in the retention of the material.  This, in turn, can help increase progress.

If you are working on categorization, comparing/contrasting, grouping, etc., you can use the same approach mentioned previously (i.e., software, self-made PPT materials).  To address following directions, all you really need is a shared whiteboard (one of the tools supplied by the web, video-conferencing platform).  You can “unshare” your desktop but still use the whiteboard to play a “Barrier Game” where one person gives a direction and you both have to draw or write it.  When everyone is finished taking multiple turns giving directions, you can “share” your whiteboard once again to compare the results of how the each person interpreted the directions.

Pragmatics (i.e., social skills) can be addressed through teletherapy as well.  Onsite, language therapy provides an extra avenue to aid the communication process because of the fully-observable, “body language” component of social skills.  While providing teletherapy, I am able to notice upper-body “body language,” but activity that occurs below the chest is difficult to see (e.g., hyper- or happy- feet, wiggling due to needing a bathroom break) due to the restricted amount of space the computer’s camera can afford.  Since clients receiving Speech/Language therapy via telepractice tend to enjoy staying in one spot, in front of the computer, having to see below the chest area is not crucial.  If a client points to something in the room during teletherapy or if there is some type of disruption off to the side of the room, I rely on my eHelper to tell me what is happening since it is typically outside of the camera’s view.  Many times I will incorporate the information the eHelper provides into the therapy session because of its immediate relevance.  I’ll ask “Wh” questions (e.g., What is making that squeaking noise?), incorporate verb tenses (e.g., Something squeaked a few seconds ago.  Was it an animal that squeaked?), and concepts (if the situation promotes them) (e.g., Did the squeak come from a door when it was opened?  What about when it is being closed?  No?  It was a mouse?  Did the mouse run under your chair?). 

Using some type of language to communicate is a common bond between everyone.  Whether language therapy is provided onsite or via teletherapy, some of the same techniques can be used in both contexts.  Based on my experience, it is just as easy, if not easier, to work on language skills via teletherapy because of the clients’ attraction to computer-based activities.  We, as Speech/Language Pathologists, need to consider collecting or creating a different therapy-material library as we enter this new professional frontier!  We need to “think outside the box” in terms of our “box of materials and tricks” and consider your computer's capability in terms of creating self-made materials as well as considering the types of materials the world-wide-web has to offer!

Links for Activities on the Web
If some of the activities are not made for use online, print & scan or just “copy” the page (save it to your computer to call up during teletherapy using your web-based, video conferencing platform).  You will then be able to use the tools to interact with the material.

Saturday, September 14, 2013

Parent Coaching for Expressive Language Development

Text Box:  Parent Coaching Strategies to

Facilitate Expressive Language Development

Mr. Coach Stock Photo - 9720845
I had the opportunity to work with a toddler diagnosed with autism, providing services using tele-therapy.  Requesting a student with autism sit in front of a computer to work (not allowing the child to do what he wants to do) is difficult enough much less one that is just turning 3.  I had to sit back and consider what would be the most efficient and beneficial way to provide services to this student and his family using tele-therapy, and the idea of “parent coaching” came to mind.  While interviewing the parents about a typical day in the life of their son, I began to wonder what their interactions looked like from a clinical point-of-view.   I decided to ask the parents to video tape their interactions with their son as well as any other interactions this young boy usually had with other therapists, etc. during a typical day.  They were comfortable with this and later sent me video clips via a private YouTube channel. 

This child’s parents were very aware of their son’s difficulties and were very in-tune with his communication needs.  However, even though this little boy appeared quite bright, it was difficult to distinguish when he was answering a question from what he had learned or if it was a rote response (i.e., a response that has been practiced when asked a specific question).  The parents had some specific goals they wanted their son to achieve, so how was I going to help them?  I had taken a course, “Making Hannen Happen,” many years ago.  The strategies provided in that training have transcended time because stimulating expressive language over the last 10 years or so generally stayed the same for the majority of children developing communication skills.
I provided this young boy’s parents with information about expressive language development following the hierarchical pattern including articles by ASHA and other authors.  I also provided hierarchical activities following his developmental pattern.  His parents’ expectations appeared to be beyond this child’s current capabilities (determined by the boy’s age as well as his disability).  I found myself in a “counseling” mode explaining why some of the skills they were trying to teach this little one were beyond his current ability level and that was one reason why they were not experiencing consistent success. 

I had to ask myself, “What are the pre-requisite skills needed to reach the goal?”  The best approach I found was to break the skills the parents’ wanted their son to learn into much smaller steps incorporating as many modalities as possible.     The boy’s father was working with him labeling items in pictures, one of which happened to be an apple.  To help the child develop actual knowledge about apples, the following were my suggestions:

1.     Have an actual apple on hand (different colored ones if possible)
2.    Talk about the outside of the apple:  color, shape, size, smell, taste, texture
3.    Cut open the apples (“What do you see?”) and eat some of each talking about how it sounds as you bite into each piece, how does it taste?
4.    Cut an apple in half the horizontal way and use washable tempera paints to make apple prints on paper using the  different colors apples can be
5.    Find a simple recipe to make applesauce or another food made from apples.
6.    Eat apple slices with peanut butter and talk about how it tastes, and what about messiness, stickiness?
7.    If possible, make a pretend apple out of PlayDoh.  Compare the “fake” apple with the real one explaining that you can eat a “real” apple but not the “pretend” one made from PlayDoh (modeling analytical thinking)
8.    Bring in another fruit such as an orange and do the same as steps #1-4, #7
9.    Try making a drinking homemade orange juice
10. Compare an apple to an orange
11.  Find video clips of people picking apples and oranges showing how
both grow on a tree
12. Add bananas doing #1-7 (tastes great with peanut butter)
13. Roll each item across the floor to see how they roll.  Compare
14. Use this method to teach common fruits you either purchase or see in the market.

*These activities would take a number of sessions.  Demonstrate and then let the child try.  Many parents I've worked with try to do it for their child.  They feel they’re helping their child (with the exception of cutting the apple into slices, of course).  I had to encourage these parents that learning involves making many mistakes.  If the apple print did not turn out as clearly as the parent wanted, they would do the next print “hand-over-hand” thus removing the child from the actual process.  Typically the child would lose interest and wander off.  Other suggestions I provided include:

15. When speaking to your child, keep your sentences simple and to the point (approximately 3-4 words per utterance, “Are you hungry?” versus “Are you ready to go have some sandwiches for lunch?”).  Expanding utterances will come along a bit later.
16. Speak slowly because it may take the child additional time to process the information.
17. Do not require the child to look you in the eye when you are speaking to him.  A glance at your face, especially at this age, should suffice.  Toddlers are busy-bodies and need to keep moving and exploring. 
a.    If you ask a child a comprehension question, he may provide a quick or rote answer in order to be able to go do what he wants to do.
18. Allow time to just play with your child.  Let the child direct the play.  Have a few toys out for him to choose from and follow his lead.
a.    Make simple remarks about what is going on, but AVOID asking questions to see if he knows the answer, “What color is your truck? How about that car? What is this part of the car called?”  This is play time, not teaching time.
b.    Model out loud how to think about items, “You have a big, blue truck!  Wow!  Mine is small.  I have a small, yellow truck. “
c.    Model out loud how to problem-solve (over-and-over-and-over again), “Oops!  The wheel came off of my truck.  Hmmm.  How can I fix it?  {looking over the whole truck while thinking}. If I get something to help the wheel stay on, I should be able to fix it.  If I use glue, the wheel may not spin…”
d.    Allow some “quiet” play time as well and let your child do the talking (or not if he so chooses).  This is a great opportunity to just sit and listen to what your child is saying (to you and/or the toys), etc.
19. I’d then ask the parents to send me a brief YouTube video while doing one of these activities.

The next session, we would discuss what seemed to work well (and not so well) while the parent(s) worked with the boy.  I’d also be ready with more activity ideas and literature for the parents.

What are some challenges or successes you’ve experienced working with parents?
Do you have any tips for making parents successful contributors?

Submitted 9/14/2013 - Cumberland Tele-therapy Blogspot

Tuesday, May 28, 2013

Join ASHA's Tele-therapy "Special Interest Group" SIG18!

If you are interested in the field of Tele-therapy, ASHA has a "Special Interest Group" called SIG 18 that has great information about this rapidly-expanding field!  As well as being a tele-therapist, I am also a member of SIG18 and have found the resources to be invaluable and very current!  Consider joining SIG18 to find out more about the field of tele-therapy!  Follow this link to view the latest SIG18 video: .

Tuesday, May 7, 2013

Want To Learn More About Tele-Therapy?

Tele-therapy FAQs

Q:  What helped me decide to become a tele-therapist?

A:  When I was interviewed, the point was made that the company was looking for someone that was interested in technology and providing therapy services.  That person would assist the company in establishing Speech/Language tele-therapy and doing it the “right way” from the start.  It was pointed out that no shortcuts would be taken. That was exactly what I was looking for, so I was sent to Maine for training by Michael Towey at the Waldo County Hospital (the only American Telemedicine Association accredited training program in the nation).
          I was given all of the necessary technology allowing me to provide HIPPA-compliant, high-quality services.  Providing a laptop and an Internet connection supporting tele-therapy were just the beginning of the company’s dedication to excellence as well as provider and client satisfaction.  Be sure request quality equipment when beginning tele-therapy services.
          I am offered additional challenges to expand my expertise which I gladly embrace.  I found myself thinking “outside of the box” from writing postings for the company’s blog to presenting information about tele-therapy to a graduate class at the UW-Madison (my Alma mater).  My opinion is requested and taken into account when the company is making tele-therapy decisions.  I actually feel validated which is something I did not experience while working on-site.
          Nothing is left to “chance.”  If I have a question or concern about scheduling students, completing paperwork, etc., the company is right there finding the answers.  I honestly have never felt so supported in my entire career!

Q:  What are the “pros” and “cons” of tele-therapy (in your opinion)?

A:   1. I’ve been asked if it more difficult to establish a provider-client relationship
over the Internet versus working on-site?
A.   I would not say it is more difficult to form a relationship; it is a different type of relationship.  If you are used to early elementary  students hugging you, that will not be possible via tele-therapy, obviously.  However, when the students see you via the webcam, you can feel the connection!  Hugs are replaced by smiling faces, giggling, and excited voices wanting to tell you they have been doing, etc.
2.    Depending on the quality of equipment you are given, hearing and seeing the students can be a challenge. 
A.   Be sure the company you work for provides the necessary equipment to do the job WELL.  Overall, it will be a reflection on you in terms of the quality of the video and audio; the clarity of the signal in general.
3.    Applying for multiple licenses to service students in different states can be time consuming, but this is a legal requirement! 
A.   The company you work for should be willing to provide you with the necessary information to help with this process as well as making follow-up calls to state boards if questions arise.

Q. I’ve heard that finding/making materials to use can eat up a large chunk of time.  How do you handle this?

A.The ATA training in Maine demonstrated how one can make materials to use relatively easily. We use a  “DropBox” account for our tele-therapists allowing us to store and share materials we’ve made for clients.  We’re building our own materials library!  Why recreate the “wheel” when someone may have already created materials to meet similar objectives?

Q:  Did you ever consider starting a private tele-therapy practice rather than work for a company?  If so, what changed your mind?

A: I briefly considered the private practice option, but I had a private speech/language therapy practice years ago and knew the amount of additional work it took to: advertise, set up billing, file paperwork for insurance and/or Medicare/Medicaid reimbursement, etc.  One of the reasons I decided to provide tele-therapy rather than continue to work on-site was because I found myself providing less therapy and spending more time dealing with behavior management, professional staff development, teacher duties (e.g., bus duty, lunch duty, recess duty), and completing all of the associated paperwork.  If anything, I wanted to decrease the amount of paperwork I had to complete.
The company I work for takes care of billing, advertising, reimbursements, etc.  I am providing more therapy now than ever before!  Working with students to meet his/her IEP goals is now my highest priority without interference from those other necessary, on-site tasks.

Q: What do you like best about the field of tele-therapy?

A: Where do I begin? 

1.     I love being able to work out of my home!  I no longer need to go out into the weather (Wisconsin winter weather can be brutal) if I do not have the need.  If the weather is warm, I can enjoy my lunch outside if I prefer.  The flexibility is wonderful!
2.     I left the on-site, school politics behind.  I am trusted to do my job and am treated like someone who has a Master’s Degree in Communicative Disorders with over 20 years of experience!
3.    I enjoy using my expertise and creativity to help develop new tele-therapy materials, as well as shaping the tele-therapy field itself!
4.    The field of tele-therapy is basically a “blank canvas” and we are the artists!  If you can think “in-” and “out-side” of the box, you have the potential to make a large difference in our profession.
5.    I enjoy working with technology, finding new ways to use it, and looking at it from different perspectives.
6.    As the field of tele-therapy grows, I enjoy the idea of learning with it.  The sky is the limit!