As speech-language pathologists, we spend a lot of time thinking about—well … speech and language. Sometimes our clients need more complex interventions, however, and we must focus on skills that come before symbolic communication or speech forms. We sometimes use the term “early communicator” to describe these individuals, which I think helps build understanding of their skills and needs.
Although they might not use conventional language forms, “early communicators” are meaningful communicators and may use any of the following tools:
- Spontaneous communication, which includes behaviors in response to environment or internal states—for example, blinking from a bright light.
- Intentional behaviors, which occur when the client acts purposefully on objects or events, such as reaching for a toy of interest.
- Intentional communication, which involves the leap in understanding that one’s actions get interpreted and responded to by partners. They may use gestures, pointing, vocalizations or eye contact to express needs or initiate exchanges.
- Symbolic communication uses an external symbol to represent an idea. Although this includes spoken and signed languages, symbolic communicators may also use nonconventional forms like pictures.
Given the complex needs of many of these clients, it’s natural to ask whether we can appropriately assess and support them through telepractice. I think telepractice works for these clients, and I gathered some existing evidence and considerations for making that happen.
Schea N. Fissel, Pamela R. Mitchell and Robin L. Alvares, along with and Anna A. Allen and Howard C. Shane, show that we can effectively modify and administer complex models like emergent literacy and evaluation of children with autism spectrum disorder through telepractice.
Start by helping parents and caregivers view early communicators as productive communicators by working with them to create an inventory of communication behaviors. More importantly, this process gives SLPs a list of signals that we can expand through intervention. Although a variety of inventory formats exist, it’s generally useful to include information on what the behavior involves, what the behavior might mean and how the partners respond.
Some of these behaviors involve subtle motor movements or vocalizations and can be difficult to observe remotely. Special hardware, such as portable cameras and adjustable focus, may help compensate for this. Even on site, creating this inventory works better as a joint effort with parents and caretakers. Training them to look for signals with you provides a good opportunity to prepare them for the work ahead, while also supporting observations you might miss on your own.
After you generate an inventory of existing communication behaviors, work to expand them into more complex communication signals. Cynthia Cress outlines a model for doing this:
- Tempt: Adapt the environment or partners to naturally elicit the client’s behavior. In other words, the team gives the client a reason to communicate. Because this may involve a lot of physical components, telepractitioners should work carefully with on-site facilitators and partners to create this environment.
- Trigger: The client’s natural response to the “Tempt.” Telepractitioners cue clients and on-site partners to focus on specific behaviors, such as: “I’m looking at your finger.”
- Transfer: Transfer the skill into more conventional forms and provide outcomes for the behaviors as if they were intentional. For example, while pointing at a desired toy, the telepractitioner may prompt the on-site partner to place a picture of the toy at the child’s fingertip. The partner gives the toy to the child.
- Touch: Use the most concrete form of feedback (often touch) to help the client realize what behavior got the response. The telepractitioner may provide auditory feedback (“You told me you wanted the ball”) while the on-site partner provides tactile feedback (patting the finger that touched the picture symbol).
Clearly we need a high degree of coordination with partners to be successful in telepractice assessment and intervention. Telepractitioners should evaluate the needs and skills of clients and on-site partners to determine how to modify and guide treatment, and whether to seek additional support or refer to other settings. However, there is potential for even indirect support through telepractice. We can use various models for Tele-AAC services, including “indirect” models. In addition, Nerissa Hall demonstrated that we can use active consult to effectively guide services to AAC users.
Although we still have a lot to learn, we understand more and more that telepractice isn’t just for simple speech and language needs. Telepractice is also an effective tool for supporting early communicators.
Nate Cornish, MS, CCC-SLP, is a bilingual (English/Spanish) clinician and clinical director for VocoVision and Bilingual Therapies. He is the professional development manager for ASHA Special Interest Group 18, Telepractice; a member of ASHA’s Multicultural Issues Board; and a past president of ASHA’s Hispanic Caucus. Cornish provides clinical support to monolingual and bilingual telepractitioners around the country. He also organizes and presents at various continuing education events, including an annual symposium on bilingualism. Nathan.Cornish@Bilingualtherapies.com