1. Using Telepractice to Deliver Auditory-Verbal Therapy toChildren with Hearing Loss & their Families K. Todd Houston, Ph.D., CCC-SLP, LSLS Cert. AVT Associate Professor School of Speech-Language Pathology& Audiology College of Health Professions The University of Akron

2. 2Learning Objectives Define the principles of Auditory-Verbal Therapy as practicedby Listening & Spoken Language Specialists CertifiedAuditory-Verbal Therapists (Cert. AVTs) and CertifiedAuditory-Verbal Educators (Cert. AVEds) Define the use of telepractice as a service delivery model foryoung children with hearing loss & their families Describe the typical Auditory-Verbal session delivered throughtelepractice Discuss the skills of parents and professionals in the use oftelepractice Describe the challenges & potential outcomes of telepractice 3. 3 Auditory-Verbal TherapyThe following Description of Auditory-Verbal Therapy andPrinciples of Auditory-Verbal Therapy were adopted by the AGBell Academy for Listening and Spoken Language on July26, 2007. www.agbellacademy.org 4. Early Diagnosis & Early 4Intervention Benefits of early immersionin audition & spokenlanguage: Same results regardlessof: Type of loss Degree of loss Socioeconomic level Other variables Permits naturaldevelopment instead ofremediation 5. 5Family Involvement:How Important is It? Factors Predicting Language Outcomes Among factors such as degree of hearing loss, age of enrollment in early intervention, nonverbal intelligence, and family involvement. Two factors predicted language, vocabulary,and verbal reasoning skills at age 5.(Mary Pat Moeller Pediatrics 106, 3 2000) 6. 6 The Two Most Important Factors Age at enrollment in EI & Family involvement Family involvement explained most of thevarianceHow do we facilitate Family Involvement? 7. 7The Promise of Early Intervention RemediationDevelopmental Approach Birth 6 yrs 8. Description of Auditory-Verbal 8Therapy Auditory-Verbal Therapy facilitates optimal acquisition of spoken language through listening by newborns, infants, toddlers, and young children who are deaf or hard of hearing. Auditory-Verbal therapy promotes early diagnosis, one-on-one therapy, and state-of-the-art audiologic management and technology. Parents and caregivers actively participate in therapy. Through guidance, coaching, and demonstration, parents become the primary facilitators of their childs spoken language development. Ultimately, parents and caregivers gain confidence that their child can have access to a full range of academic, social, and occupational choices throughout life. Auditory-Verbal therapy must be conducted in adherence to all 10 Principles of Auditory-Verbal Therapy. 9. 9Parents and AVTWhen parents learn how to integrateauditory-verbal techniques into everydaymeaningful activities and experiences, theirchildren have the best opportunity to achievegood listening and language outcomes.Parents can become the professionalsgreatest allies. To ignore their contribution isto compromise a childs future. --- Judith Simser 10. 10Family Empowerment.. A primary goal of A-V practice Competent and capable parents vs dependency on professionals Parent engagement in all aspects of the childshabilitation Parent-professional partnership based on opencommunication, trust, respect, shared responsibility Begins with helping families identify what they wantfor their child 11. 11Introducing the A-V Approach toParents: Helpful Resources A-V Principles AG Bell Academy for Listening & SpokenLanguage 101 FAQs (Fall 2012); 50 FAQs About AVT Edited by W. Estabrooks - available through AGBell We CAN Hear and Speak The Power of A-V Communication for Children Who Are Deaf orHard of Hearing - available through AG Bell Children with Hearing Loss: Developing Listening & Talking,2nd Edition by Cole & Flexer Plural Publishing You Tube Videos Many AVT videos now available 12. 12 Ensuring Successful Auditory-Verbal TherapyPrinciples of AVTWhat It Takes To detect hearing loss as Ensuring newborn has hearingearly as possible throughscreening & follow-up visits; 1-3-screening in the newborn 6 Modelnursery & throughoutchildhood. Extra time for audiological management. The may mean To pursue prompt & vigorousmore frequent trips to themedical & audiologic audiologist than parents whomanagement, includingchoose a different approach.selection, modification, and Could mean seeking a strongmaintenance of appropriate pediatric audiologist who has thehearing aids, cochlear necessary experience, perhapsimplants, FM, etc. not in their community. Wearing technology 24/7 13. 13Ensuring Successful Auditory-VerbalTherapyPrinciples of AVTWhat It Takes Guide & coach parents to Weekly AVT sessionshelp their child use hearingas the primary sensory Regular attendance, comemodality in developing prepared to learnspoken language w/o use ofsign language. Entire family must be supportive of the approach Daily individual play time with child in a quiet environment (1 hour min) High expectations for listening 14. 14Ensuring Successful Auditory-VerbalTherapyPrinciples of AVT What It Takes Guide & coach parents to Active participation in AVTbecome the primarysessionsfacilitators of their childslistening & spoken language Parents must understand theydevelopment through activeare the primary consumers ofconsistent participation in the approach, not the child.AVT. 15. 15Ensuring Successful Auditory-VerbalTherapyPrinciples of AVT What It Takes Guide & coach parents to Control background noisecreate environments thatwithin the home.support listening for theacquisition of spoken Designated time each daylanguage throughout the spent talking, reading, &childs daily activities. facilitating listening &spoken language. Goals integrated during dailyroutines: bath time, dinnertime, going on walk, etc. Auditory Learning vs.Auditory Training 16. 16Ensuring Successful Auditory-VerbalTherapyPrinciples of AVT What It Takes Guide & coach parents to Focus on auditory learninghelp their child integrateduring regular care giving &listening & spoken language play activities (3-4 hours perinto all aspects of the childs day minimum)life. Control background noise;children must be able to hearspoken language w/o the t.v.,radio, etc. Listening become a part ofchilds personality; s/hewants to wear technology 17. 17Ensuring Successful Auditory-VerbalTherapyPrinciples of AVT What It Takes Guide & coach parents to Typical language development isuse natural developmental followedpatterns of speech,language, cognition, & Childs progress is measuredcommunication.against hearing peers An average or better thanaverage rate of progress shouldbe expected Speech therapy may be needed;should follow AV principles 18. 18Ensuring Successful Auditory-VerbalTherapyPrinciples of AVT What It Takes Guide & coach parents to Child progresses through normalhelp their child self-monitor stages of learning speech:spoken language through vocalizes, plays with voice,listening.produces vowels BEFORE s/hesays words. Develop the auditory-feedbackloop Child begins to monitor thespeech of others & self-monitors their own speech 19. 19Ensuring Successful Auditory-VerbalTherapyPrinciples of AVTWhat It Takes Administer ongoing formal & Parents must support ongoinginformal diagnosticmonitoring of progressassessments to developindividualized Auditory-Verbal Could mean extra visits fortreatment plans, to monitorformal diagnostics; depending onprogress, & to evaluate theinsurance, could mean highereffectiveness of the plans for expensethe child & family. Understand sessions are diagnostic in nature but not testing the child every time 20. 20 Ensuring Successful Auditory-Verbal TherapyPrinciples of AVTWhat It Takes Promote education in Parents actively involved inregular schools with peers transition process fro EI towho have typical hearing & public schools (or privatewith appropriate servicesschool)from early childhoodonward. Mainstreamed education is the goal, with proper supports in place Child should have language ability to be successful 21. 21A-V IS WORKING for a variety offamilies because A-V facilitates a mutually satisfying parent-professionalrelationship From the Professional Perspective: Professionals desire to help but do not want the totalresponsibility for the childs outcome Given A-V training, professionals can provide parents with cutting-edge information, high-level intervention skills, fact-basedinformation & documented outcomes consistent with parent goals 22. 22 A-V IS WORKING for a variety of families because A-V facilitates a mutually satisfying parent-professional relationship From the Parent Perspective: A-V employs a problem-solving approach that empowers the parent to take responsibility in decision- making Parent input/questions are welcomed Parents are included in every activity 23. 23 Parent Support, Education and Guidance in the A-V Approach Parents are included in every activity. What isinvolved in including the parent? In A-V, the parent IS the student BUT Teachers/SLPs are trained to work withchildren, not adults 24. 24The ultimate potential for the childto become a successful language-useris directly related to parentinvolvement. Parents are the magicand parental buy-in (what it takes) iswhat makes the magic work! (K. Anderson, 2005) 25. 25What is Telepractice? The application of telecommunications technology todeliver professional services at a distance by linkingclinician to client, or clinician to clinician forassessment, intervention, and/or consultation.(ASHA, 2004a) Services provided solely by correspondenceshould not be considered acceptable applicationof telepractice.(American Speech-Language-Hearing Assn.2005) 26. 26Terminology 27. 27Benefits to Telepractice Services Provides access to qualified providers Decreases travel constraints Reduces health-related cancellations Facilitates access to interpreters Increases use of family-centered coachingstrategies Intensifies family member involvement Provides opportunities to work as a team 28. 28Providing Access to Qualified Providers Many children are not receiving appropriate services Severe shortage of early childhood professionals withadequate knowledge & training to effectively educate Lack of a critical mass of children who are D/HH in aspecific geographic area Resulting in difficulty finding qualified providers in that area Listening and Spoken Language Specialists(LSLS) are often in demand in rural areasand can be accessed through telepractice 29. 29Decreasing Travel Constraints Travel-related expenses can consume a large part of aprograms budget; TI can reduce direct expenses such asmileage reimbursement and professional time Travel time for professionals can be significantlydecreased, allowing more children to be served in thesame amount of time Eliminates the familysneed to travel to a clinic Avoids the effect of inclementweather resulting in cancelledsessions 30. 30Reducing Health-Related Cancellations Health-related cancellations can be reduced whenthe child only has a minor illness and can stillparticipate Doesnt expose the early interventionist to illnesses Can decrease exposure of chronic health conditionsto others, reducing the risk of health problems Decreased cancellations forfamilies participating in TI 31. Increasing Use of Family-31Centered Coaching Strategies Families can learn new skills to interact with theirchild through coaching by increasing parentknowledge and improving parent-child interactions The coach (early interventionist/professional)supports and encourages parents as they learn andpractice new strategies by providing ongoingfeedback Coaching is an important part offostering listening and spoken languagein children who are D/HH. 32. 32 Intensifies Family Member Involvement Opportunity for all family members to benefit and beinvolved in the early intervention Ability to record and store sessions Can be shared with family members and professionals onintervention team Family members absent from session can learn strategiesused All family members can observe week to week progress Videos can be posted on secure website for ongoingaccess Can be shared with friends and other caregivers 33. 33Challenges of Tele-Intervention Accessing a high-quality internet connection Feeling confident with technology Having a quiet space in the home Assuring providers have skills with technology andintervention Recognizing telepractice isnt for everyone Obtaining reimbursement Accessing materials 34. 34Feeling Confident with Technology Some families are not confident in usingtechnology, regardless of training Can influence decision to participate in TIservices There are ways to simplify technology, such asusing a laptop with built-in camera, microphone,and speakers Availability of a technical support staff may ensurecontinued services when trouble-shooting problemsoccur 35. 35Skills Checklist for Providers of Telepractice Has basic knowledge of computers and other equipment being used Can trouble-shoot video and audio equipment Attends to technology while conducting the session Organizes materials for activities ahead of time based on naturally-occurring routines Conducts activities that involve materials and actions that areeasily depicted over video/audio Has a variety of activities planned in case some are not successful Can adjust activities based on immediate interests of child Demonstrates use of coaching techniques when working w/ family 36. 36Accessing Materials Preparing materials for a telepractice session maybe more time-consuming Using a coaching model requires the interventionistto have two sets of materials: one for theinterventionist to use during demonstration andone for the caregiver to use at home Additional time is often needed to make sure thatthe family and the interventionist have allmaterials ready prior to starting the session 37. Implementation of Telepractice37Services Services must adhere to ASHA Telepractice ServiceDelivery Guidelines Important that services are keeping with recommendedfamily-centered intervention practices A good telepractice session should look the same as ahigh-quality traditional home visit Recommended practices include: The use of coaching strategies Routines-based interventions Naturalistic teaching opportunities 38. Preparing for a Telepractice 38Session Create a listening environment Limited distractions &background noise,check listening device Management of others in the environment Ensure others know when sessions are & not tointerrupt Selecting instructional materials Use culturally and developmentally appropriate 39. 39Technology and Home EnvironmentTelepractice Checklist Prepare your environment Choose optimal room, have materials ready,remove distractions, prepare child for session Prepare your equipment and connection Make sure equipment is on and working, reduceinterfering internet connections Ending the session Discuss problems, plan date and time of nextsession, notify others that session has ended 40. Conducting the Telepractice40Session1. Reviewing goals and activities Reviewing goals from previous week, new updates,review goals for current session, check hearing devices2. Conducting the lesson/activity Demonstration of new strategies/techniques, coachingthe parent, discuss integration of goals into daily homeroutines3. Debriefing Allow questions from parents, discuss continuation orselection of new goals, summarize session and goalsfor the coming week 41. 41Monitoring Child Development &Audiological Functioning Via Telepractice Monitoring child developmental progress in an importantpart of early intervention Observation scales and language samples are a good wayto evaluate via telepractice Session recordings can be used to evaluate childperformance with observation scales or to codelanguage samples Inter-rater reliability checks Opportunities to consult with theaudiologist, other professionals 42. 42Technologies Overview The videoconferencing system uses digitalcompression of audio and video streams in real time Codec: coder/decoder Other requirements: Video input- video camera/webcam Video output- computer monitor, TV, projector Audio input- microphones Audio output- usually loudspeakers Data transfer- analog/digital phone network, LAN, internet Computer 43. 43Types of Videoconferencing Systems Dedicated Systems Have all required components packaged intosingle piece of equipment Types: large group, small group, and individualvideoconferencing Desktop Systems Add-ons (usually hardware boards) to normalPCs, changing them into videoconferencingdevices Use a range of different cameras andmicrophones 44. 44Technology Considerations Up-front Costs Quality of Equipment(video, image size, camera Ongoing Service Feespan, and zoom) Bandwidth Recording telepracticesession Bandwidth Reliability Security Technology Maintenance &Support How to Create Optimal Security Ease of Use 45. 45 Proposed Outcomes of Telepractice Increased parent knowledge, skills in cultivatingdevelopment, satisfaction with services and providers Increased child developmentaland communication outcomes Improved parent-child interactions Important to measure impact of telepractice on: Increased frequency & intensity of intervention;provider skills and competence; use of time;decreased costs in regards to travel time 46. Beneficial Outcomes Reported by46Families Better knowledge of language development process Increased skills and confidence in encouraging childslanguage and listening Child responsiveness to parent improved Augmented child language development & listeningskills Increased skills of family members as coaches 47. 47Nancy & Alex 48. 48Nancy & Alex 49. 49Nancy & Alex 50. 50Summary Newborn hearing screening, early diagnosis of hearingloss, early intervention, early fitting of hearingtechnology all lead to better communication outcomesfor children with hearing loss & their families Parents want access to well-trained professionals whohave the knowledge & skills to facilitate listening &spoken language, such as Auditory-Verbal practitioners Because of cheaper technology & access to broadbandInternet connections, telepractice is a viable model ofservice delivery that is increasing in the United States &around the world! 51. 51Thank you for listening! K. Todd Houston, PhD, CCC-SLP, LSLS Cert. AVTAssociate Professor of Speech-Language PathologySchool of Speech-Language Pathology & AudiologyThe University of Akron(330) 972-6141 Houston@uakron.eduFacebook: Todd Houston LinkedIn: Todd HoustonLinkedIn Group: 6 Sound Off