Samyukta Gaddam, Byron Ross* University of Houston
Introduction
As the world becomes more digitized, healthcare professionals are adapting to these changes by making healthcare more accessible. One such field is Speech-Language Pathology (SLP), which treats speech and swallowing disorders. With the onset of COVID-19, many SLPs switched to online methods of therapy, thus reinvigorating teletherapy as a viable model. Because the exigence was sudden, leaving little time for preparation, many SLPs lacked appropriate training in teletherapy. Coupled with the lack of research in the field, teletherapy outcomes were ambiguous, presenting as both successful and unsuccessful; however, with more research and data on teletherapy, future online therapy may become a quality form of therapy for those seeking speech treatment. This research endeavors to contribute to the growth of teletherapy by studying teletherapy effectiveness for individuals with Autism Spectrum Disorder, considering multiple age groups and severity levels. This research study presents a meticulous literature review along with an in-depth explanation of the research method, findings, discussions, and conclusions.
Speech-Language Pathology
Speech-Language Pathology (SLP) is a field of expertise in the communication sciences and disorders discipline and is practiced by Speech-Language Pathologists (SLPs). SLP services range from increasing fluency in speech to improving one’s swallowing ability. The goal of these services is to overcome communication barriers that result from speech impediments or Developmental Language Disorders (DLD), which are neurodevelopmental conditions developed in childhood that make learning, understanding, and using spoken language difficult. DLD symptoms can be either expressive (syntax, vocabulary, motor skills, etc) or receptive (comprehension skills).
Autism Spectrum Disorder & DLD
Individuals with Autism Spectrum Disorder (ASD), a neurodivergent condition hindering social communication and interaction, are more likely to have speech impairments. In fact, 63% of children with ASD are also diagnosed with language impairment. These impairments include reciprocal social interactions, language-structure deficits, and a delay in language acquisition. However, it is important to note that, although many ASD individuals have both expressive and receptive language disorders, there are also a number of individuals with ASD who don’t display any language impairments (National Institute of Mental Health).
SLPs provide communication and social skills to individuals with ASD to improve their quality of life. Treatment plans may include: using a variety of communication supports, taking turns in conversations, or moving from one activity to another. Caregivers are also given coaching to communicate with their children and to improve communication skills. SLPs also support ASD adults, who are transitioning to work,in interviewing, advocating for themselves, and learning strategies to communicate at work (American Speech and Hearing Association).
Different Models of Speech Therapy
Traditional SLP services are usually given face-to-face; however, there are many barriers to receiving these services. Because of the nationwide shortage of SLPs (especially in public schools), there are long waitlists and delays in accessing services, which can hinder the early identification of DLD and the effectiveness of future treatment. Individuals with ASD and those living in rural areas are particularly at a disadvantage in accessing SLP services. The onset of the COVID-19 pandemic also significantly restricted the delivery of SLP services. This unique predicament made telepractice a viable option during the COVID-19 pandemic as it had the potential to reach underserved populations (American Speech and Hearing Association).
Telepractice is the use of technology to deliver clinical services like speech therapy. It often comes in three models: synchronous, asynchronous, and hybrid. Synchronous service delivery is done through a live video session or other form of live interaction between the clinician and the client. Asynchronous telepractice consists of services provided to the client when the clinician is not present, for example, pre-recorded video lessons that can be accessed by the client and family members. Hybrid telepractice utilizes both synchronous and asynchronous models, for example, allowing clients to have access to live video sessions as well as pre-recorded sessions (American Speech and Hearing Association).
Awaji’s Study
In 2022, Nirsen Awaji (Saudi Arabia) investigated changes in SLP roles during the COVID-19 pandemic, which was influential in turning the majority of service deliveries in SLP online. The study surveyed SLPs on the benefits and challenges of using telepractice, determining one such benefit to be increased flexibility and family involvement. However, SLPs in the survey identified that telehealth would be least beneficial or effective with individuals with cerebral palsy or autism (Awaji). This research study focuses on the knowledge gap indicated by the limited research done on telepractice and its effectiveness as well as an empirical gap because the findings of Awaji's study are contrary to the findings of other studies
Marotta’s Study
Unlike the study conducted by Awaji, Myranda Marotta’s study specifically compared the effectiveness of telepractice versus the effectiveness of in-person therapy for individuals with ASD. The study identified a lack of scientific merit behind previous studies on the topic, addressing this gap by conducting a quasi-experimental, single-subject, multiple groups, and time series design. Marotta found that telepractice was an effective method for ASD individuals, increasing their independence and thus optimizing the client's quality of life, contrary to Awaji’s study (Marotta). This merits further study to evaluate whether telepractice is truly effective for individuals with ASD.
Boisvert’s and Lang’s Study
Boisvert and Lang (2022) compared the effectiveness of telepractice and in-person therapy for individuals with ASD, utilizing a comprehensive literature review with a five-step systematic search procedure, including keywords, no restrictions on publication date, English-language publications, inclusion criteria, and additional work by the prospective author. 7 out of 8 studies found telepractice to be beneficial for individuals with ASD. However, the study also states that some of its limitations include the lack of studies in the area of teletherapy’s effectiveness (Boisvert, Lang).
Research Gap
A majority of prior research on telepractice effectiveness only addresses the general population or the ASD population as a whole, without considering different age groups and severity levels. This research attempts to address this knowledge gap by analyzing SLP telepractice effectiveness and differences for each age group and severity level.
Research Question and Purpose
“To what extent is telepractice as effective as in-person therapy for individuals with ASD?”
Due to the COVID-19 pandemic, it is clear that more rigorous research on telepractice is needed, especially concerning individuals with ASD. Because of the lack of research, there is little training provided to SLPs on optimizing telepractice usage. As a result, SLPs have limited experience and knowledge about this method of intervention. Thus, exploring telepractice may help inform SLPs about this method’s effectiveness. Subsequently, this study may help optimize therapy results by shifting clients to teletherapy, as findings demonstrate the benefit of online therapy.
Furthermore, increase in SLP teletherapy could increase SLP access for the less fortunate.Additionally, this study could influence further research and SLP training .
Focus
This study compares SLP telepractice effectiveness within variable age groups and severity levels of autistic individuals The goal is to reduce the knowledge gap by focusing on how effectiveness differs in terms of severity levels, age groups, short-term goals, and daily objectives for both models. Thus, rather than broadly comparing the effectiveness of the two models, as previous researchers have done, this study allows for more nuanced and informed findings, indicating which model and aspects are more effective.
Hypothesis and Assumptions
I hypothesize that telepractice is as effective as in-person therapy for adults, school-age children because patients can work with more autonomy and less guidance from the therapist, improving treatment in an online environment. I also hypothesize that telepractice
is as effective as in-person therapy for Level 1 clients because they require the least support and guidance compared to other levels on the DSM-5 ASD scale, as clients can have more autonomy. Online therapy tends to have less direct interaction, allowing clients to buid more independence and thus work on tasks with less guidance or interaction from therapists.
Thus, adolescents and adults are likely to perform better in an online setting because the autonomous structure of the therapy may strengthen their self-confidence and ability to perform tasks independently. The same goes for Level 1 clients, who require little assistance from the therapists and thus may perform equally well in either model.
Method and Procedure
To assess teletherapy effectiveness, practicing ASD Speech-Language pathologists within the US were surveyed via multiple-choice and free-response online questions to gather quantitative and qualitative data. Participation was voluntary, and participants were given consent forms prior to participation, with the option to withdraw from the study at any time. The survey was divided into 4 parts.
Surveys are a common method used by Speech-Language Pathology experts, and are used because they are , convenient, easy, cost-effective, and efficient in compiling multiple perspectives from a diverse cohort of SLPs.
Survey Breakdown
Part 1 of the survey consists of demographic information, , consisting of questions ranging from years of SLP teletherapy, to experience with ASD patients. To verify their qualifications, the survey asked for the highest degree earned (Bachelor’s, Master’s, Ph.D.), as well as if they were licensed and/or certified. These questions evaluate SLP credibility and study eligibility, which requires SLPs to have at least some experience working with both telehealth and ASD individuals. Based on the responses, target participants were filtered.
Part 2 of the survey asks questions about telepractice therapy outcomes, using a Likert scale. SLPs chose a value which best reflected how often they were able to meet their daily and short term goals for different age groups and severity levels, on a scale of 1 to 5 with 1 being never and 5 being the most often. Age groups include infants and toddlers, preschoolers, school-age children, and adults. Severity levels are based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5): Level 1 (requires support), Level 2 (requires substantial support), and Level 3 (requires very substantial support). The scales are included individually for each age group and severity level, separated by daily objectives and short-term goals.
Part 3 of the survey repeats questions from Part 2, but the questions ask about the therapy outcomes during face-to-face therapy. Part 2 and Part 3 are critical because they determine the effectiveness of both models and allow for comparison. This analysis was then applied to each age group and severity level concerning the frequency of goals met for short-term and daily objectives.
Part 4 of the survey has a mixture of free-response questions and Likert scales to gather and analyze SLP perspectives and opinions on working with ASD individuals, using telepractice versus face-to-face therapy. The free response questions directly ask SLPs whether they think teletherapy is as effective as in-person therapy for autistic clients and for what age groups and severity levels they think teletherapy is as effective as in-person therapy. These questions prompt them to elaborate on their answers, asking for explanations on why they think certain groups benefit more than others from the different models. Additionally, the Likert-scale questions prompt participants to choose from a scale of strongly agree to strongly disagree for 5 statements.
Part 4 is also essential for answering the research question in allowing the responses to be analyzed, as they indicate what factors make each model more or less effective than the other. Part 4 sets itself apart from Part 3 because this section focuses on the perspectives and opinions of SLPs. It gives them more room to elaborate on their answers and add details that Part 3 didn’t cover. Relative to Part 4, Part 3 is more objective as there’s a clear indicator of what would make one model more effective than the other; the frequency of meeting goals does not only give a specific parameter but also provides quantitative data.
However, gathering qualitative data with more varied responses would also help answer the research question because variables that were not accounted for in Part 3 can be mentioned in Part 4 with the free responses. It would also give an idea of what SLPs personally think about teletherapy versus in-person therapy: it could be that they were able to meet more goals in teletherapy but would still prefer in-person therapy for certain reasons. The Likert scales in Part 4 are also necessary for answering the research question as it accounts for more variables that can conclude the effectiveness of the different models.
Primarily, it focuses on the ease of each model and the amount of interaction between the client and therapist. Thus, if a certain model seems to be easier to use, it may indicate the model’s effectiveness or at least provide a reason for why the model yields more successful outcomes as a result of more goals being met.
Distribution
The survey was done on a Google Form and settings were altered so that participants’ email addresses and personal information were not collected. The primary method of distribution was emailing SLPs nationwide. The survey was published on the online community posts on the ASHA website as well as TSHA’s and HSHA’s. Additionally, the survey was distributed to SLP organizations on social media. The study received 14 participants.
Analysis, Results, and Conclusions
The results were analyzed using the Kruskal-Wallis Test, which identifies whether differences in groups are significant or not. Initially, ANOVA was used, but because the data distribution did not support the normality condition, the Kruskal-Wallis Test was the ideal option as it didn’t have parameters on conditions or normality. Further, the significance level was 0.05.
The null hypothesis when testing for how often SLPs were able to meet daily objectives for preschoolers and school-age children was that teletherapy and in-person therapy are equally as effective for preschoolers and school-age children. The alternate hypothesis was that in-person therapy was more effective (because it had a higher mean). The Kruskal-Wallis Test for these two groups (see Table 1) resulted in a p-value of .0081 and .24821 (for preschoolers and school-age children respectively). Thus, there’s convincing evidence that in-person therapy is more effective for preschoolers; however there is a lack of evidence that in-person therapy is more effective for school-age children. Therefore, the null hypothesis is rejected in the case of preschoolers but we fail to reject the null hypothesis in the case of school-age children.
Because there wasn’t a large enough sample size for the infants and toddlers group if the daily objectives and short-term goals are assessed separately, the results for short-term goals and daily objectives were grouped. The null hypothesis was that teletherapy is as effective as
in-person therapy for infants and toddlers. The alternative hypothesis is that in-person therapy is more effective. The p-value was .02031 (see Table 1), so we reject the null hypothesis since there’s convincing evidence that in-person therapy is more effective.
Because there wasn’t a large enough sample size for the adult group, if we assess the daily objectives and short-term goals separately, the results for short-term goals and daily objectives were grouped again. The null hypothesis was that teletherapy is as effective as in-person therapy for adults. The alternative hypothesis is that teletherapy is more effective (it had a higher mean). The p-value was .21935 (see Table 1), so we fail to reject the null hypothesis since there’s no convincing evidence that teletherapy is more effective. Thus, teletherapy and in-person therapy are equally effective for adults.
The null hypothesis when testing for how often SLPs were able to meet short-term goals for preschoolers and school-age children was that teletherapy and in-person therapy are equally as effective for preschoolers and school-age children. The alternate hypothesis was that in-person therapy was more effective (because it had a higher mean). The Kruskal-Wallis Test for these two groups (see Table 1) resulted in a p-value of .02334 and .15721 (for preschoolers and school-age children respectively). Thus, there’s convincing evidence that in-person therapy is more effective for preschoolers but we don’t have convincing evidence that in-person therapy is more effective for school-age children. Therefore, we reject the null hypothesis in the case of preschoolers and fail to reject the null hypothesis in the case of school-age children.
The null hypothesis when testing for how often SLPs were able to meet daily objectives for Level 1, Level 2, and Level 3 clients was that teletherapy and in-person therapy are equally as effective. The alternate hypothesis was that in-person therapy was more effective. The values when comparing the different models for Level 1, Level 2, and Level 3 clients respectively are .07095, .02575, and .00389 (see Table 2). Thus, for the Level 1 group, we fail to reject the null hypothesis, so in-person and teletherapy are equally effective. However, for the Level 2 and Level 3 groups, we reject the null hypothesis, so in-person therapy is more effective for Level 2 and Level 3 clients.
The null hypothesis when testing for how often SLPs were able to meet short-term goals for Level 1, Level 2, and Level 3 clients was that teletherapy and in-person therapy are equally as effective (see Table 2). The alternate hypothesis was that in-person therapy was more effective. The p-values when comparing the different models for Level 1, Level 2, and Level 3 clients respectively are .13097, .06964, and .00195 (see Table 2). Thus, for the Level 3 group, we rejected the null hypothesis, so in-person was more effective. However, for the Level 1 and Level 2 groups, we fail to reject the null hypothesis, so in-person therapy and teletherapy were equally as effective for Level 1 and Level 2 clients.
Daily Objectives | P-Value | Significant? | Short-Term Goals | P-Value | Significant? |
Infants and Toddlers | .02031 | Yes | Infants and Toddlers | .02031 | Yes |
Preschoolers | .0081 | Yes | Preschoolers | .02334 | Yes |
School-Age Children | .24821 | No | School-Age Children | .15721 | No |
Adults | .21935 | No | Adults | .21935 | No |
Table 1. Effectiveness of teletherapy compared to in-person therapy, categorized by age group.
Daily Objectives | P-Value | Significant? | Short-Term Goals | P-Value | Significant? |
Level 1 | .07095 | No | Level 1 | .13097 | No |
Level 2 | .02575 | Yes | Level 2 | .06964 | No |
Level 3 | .00389 | Yes | Level 3 | .00195 | Yes |
Table 2. Effectiveness of teletherapy compared to in-person therapy, categorized by severity levels.
Discussion & Implications
Based on these findings, it can be concluded that in most cases, in-person therapy is more effective than teletherapy. The only cases in which they are both equally as effective are for school-age children, adults, Level 1 clients, and Level 2 clients when considering short-term goals. Thus, this supports the hypothesis but something unexpected was the significance of the frequency of goals met for Level 2 clients: teletherapy seems to be as effective as in-person therapy for Level 2 clients as most SLPs were able to meet their short-term goals often regardless of which model they were using. However, they were not able to achieve this for daily objectives when using telepractice; this indicates that objectives were harder to achieve on a daily basis for Level 2 clients when using telepractice, but ultimately, they were able to meet the short-term goals regardless of the model.
On the other hand, there’s convincing evidence that in-person therapy is more effective for preschoolers, infants and toddlers, Level 3 clients, and sometimes Level 2 clients. This is reasonable considering that managing preschoolers and infants and toddlers with ASD can be challenging to do online. For instance, it would likely be harder to maintain their attention, and SLPs may not be able to have the same interaction they would need to effectively reach results. Level 3 clients are also on the more severe spectrum of ASD; as a result, they would need the most support and direction from the SLP, which would be hard to sustain through teletherapy.
While this supports the hypothesis and doesn’t deviate from the expectations significantly, the results are slightly different from what other researchers have found and add more complexity to what is already known. As seen from Marotta’s study and Boisvert’s and Lang’s study, teletherapy was concluded to be as effective as in-person therapy for individuals with ASD. However, this may not be entirely accurate as this research adds parameters to the extent to which teletherapy is effective for individuals with ASD. These findings suggest that telepractice is only as effective when SLPs work with school-age children, adults, Level 1, and Level 2 clients. The most effective therapy sessions conducted with telepractice may be for school-age children and adults with Level 1 severity. However, for all other demographics evaluated, in-person therapy was more effective and preferred by SLPs.
These findings may be important and helpful for the speech therapy field as it shows that teletherapy can be a viable option to build on in the future. Especially when considering the shortage of SLPs, there’s a need for creative solutions to fill these gaps. Even with little training and research on using telepractice, teletherapy was found to be effective for certain demographics in this study; with more robust training and research, teletherapy can be a reliable model to provide services from. As of now, while teletherapy may not be ideal for infants or preschoolers with ASD and level 3 clients, it can substitute for in-person therapy when SLPs work with older clients with Level 1 or Level 2 ASD.
Limitations
This research study relies on a small sample, which may cause discrepancies in the results. Using a survey enabled increased engagement from participants than would have been possible if an experimental design was used instead.Nonetheless the number of participants is still relatively small compared to that of previous studies. Additionally, since participants have to reflect on their past sessions using telepractice, they may not be able to accurately report or recall the frequency of meeting goals and thus the effectiveness. This potential inaccuracy in reporting information is due in part to the nature of the research method (survey): the study is performed over a year after the pandemic peaked, so details reported by the participants about the sessions during the pandemic may not be accurate and somewhat biased. However, a survey was still preferred because an experimental method would further reduce the sample size.
Conclusions
To summarize, the research gap that prompted the development of this study was that there was insufficient research done on teletherapy in the SLP field. Furthermore, existing research that did address telepractice in speech language pathology failed to discuss how the effectiveness of teletherapy varied across the different age groups and severity levels of individuals with ASD. The initial hypothesis was that teletherapy would be effective for Level 1 clients and for adults and school-age students, and this turned out to be largely true based on the results. However, some other interesting observations from the research were that while school-age clients had good outcomes with teletherapy, some SLPs preferred doing in-person with such clients because they believed it would enhance their treatment even further. There were also instances where teletherapy outperformed in-person therapy for adults, so telepractice may be beneficial for such clients. Overall, this study found teletherapy to be as effective as in-person therapy for older age groups and lower severity levels, and in-person therapy to be more effective for younger age groups and higher severity levels.
Future Research
Future research can focus on the effect of training on perceptions of telepractice as many SLPs regarded telepractice negatively and didn’t want to continue with it. This may be due to the lack of training given for teletherapy, so with more resources and knowledge available about the new technology, SLPs may become more receptive to practicing teletherapy. Additionally, future research can conduct an experimental procedure addressing this research question. This study relied on surveys and the memory retention capacity of SLPs; any bias or foggy memory can be accounted for by an experimental method that can draw causation between the two variables.
References
National Institute of Mental Health (February 2023). Autism Spectrum Disorder. U.S. Department of Health and Human Services, National Institutes of Health. https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd
American Speech-Language-Hearing Association (n.d.). Telepractice. (Practice Portal).
Awaji, Nirsen. (January 2022). Changes in speech, language and swallowing services during the Covid-19 pandemic: The perspective of speech-language pathologists in Saudi Arabia. ASHAWire. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0262498#sec021
Marotta, Myranda. (May 2022). The Efficacy Of A Telepractice Service Delivery Model For Providing Speech And Language Services To Children With ASD. Masters Theses. https://doi.org/10.7275/28956717
Boisvert, Michelle & Lang, Russel et al. (October 2010). Telepractice in the assessment and treatment of individuals with autism spectrum disorders: A systematic review. Developmental Neurorehabilitation. http://dx.doi.org/10.3109/17518423.2010.499889