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International Journal of Telerehabilitation
• Vol. 9 No. 1 Spring 2017
• (10.5195/ijt.2017.6219)
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THE EFFICACY OF TELEHEALTH-DELIVERED SPEECH
AND LANGUAGE INTERVENTION FOR PRIMARY
SCHOOL-AGE CHILDREN: A SYSTEMATIC REVIEW
DANIELLE WALES, BSPPATH (HONS), LEISA SKINNER, BSPPATH (HONS), MELANIE
HAYMAN, PHD
SCHOOL OF HEALTH, MEDICAL AND APPLIED SCIENCES, CENTRAL QUEENSLAND UNIVERSITY,
ROCKHAMPTON QLD, AUSTRALIA
In Australia, over 17% of children are considered to be
vulnerable (<10th percentile) or at-risk (10-25th percentile)
for developing impairments in language and literacy
(McCormack & Verdon, 2015). Another 25% of children are
vulnerable or at-risk for developing impaired communication
skills (McCormack & Verdon, 2015). The majority of these
children are located in rural communities across Australia
(McCormack & Verdon, 2015). Despite the high proportion
of vulnerable/at-risk children residing within these
communities, access to specialist care services, such as
speech-language pathology (SLP), is limited. In fact, recent
data (Health Workforce Australia [HWA], 2014) suggests
that less than 24% of all employed speech-language
pathologists in Australia work within these regions,
indicating that a significant imbalance exists between the
SLP services available in rural areas compared to major
cities. Specifically, research suggests that between 0.59 and
1.69 speech-language pathologists are available per 10,000
people in very remote and outer regional areas of Australia,
compared to 2.59 speech-language pathologists per 10,000
people in the major cities (HWA, 2014).
Regardless of location, speech and language skills are
a strong predictor of success in education, social
participation, and employment. Children with communication
difficulties progress more slowly in reading and writing and
experience increased bullying and poorer peer relationships
(Law, Boyle, Harris, Harkness, & Nye, 1998; McCormack,
Harrison, McLeod, & McAllister, 2011). Speech and
language difficulties not only threaten academic
performance during the school years, but also have a
considerable impact on social and vocational inequalities in
adulthood (Johnson, Beitchman, & Brownlie, 2010; Law et
al., 1998; Ruben, 2000; Schoon, Parsons, Rush, & Law,
2010; Whitehouse, Watt, Line, & Bishop, 2009). In
particular, individuals with persisting communication
problems have increased difficulty interacting with others,
sustaining employment, and living independently (Clegg,
Hollis, Mawhood, & Rutter, 2005). A history of
communication difficulties is also linked to a higher rate of
psychiatric disorders, particularly anxiety (Beitchman et al.,
2001). Given the prevalence and associated impact of
communication difficulties in rural Australian children, it is
important that SLP intervention is available to these children
to assist in the development of vital communication skills
(Law, Garrett, & Nye, 2003).
As a solution to the inequity of access to SLP services
in rural areas, some practices/practitioners have begun to
make use of an innovative service delivery approach,
commonly referred to as telehealth (Speech Pathology
Australia [SPA], 2014). This term refers to “the application of
ABSTRACT
The purpose of this article is to determine if telehealth-delivered speech-language pathology interventions are as effective
as traditional in-person delivery for primary school-age children with speech and/or language difficulties. A systematic review
was conducted (in accordance with PRISMA guidelines) using five databases, two journals and reference lists. Titles and
abstracts were screened for inclusion, with relevant studies reviewed in full-text. Initial searches identified 132 articles.
Following exclusion of non-relevant studies, seven articles remained for inclusion. Results revealed both telehealth and in-
person participants made significant and similar improvements when treatment effects were measured through five of the
six outcome measures. Findings showed there is limited but promising evidence to support telehealth for delivering speech-
language pathology intervention services to school-age children. Whilst this is encouraging, particularly for rural children
where in-person services are limited, more rigorous study designs are required to support the efficacy of telehealth for this
population.
Keywords: Intervention, Language, Primary School-age, Service Delivery, Speech, Speech-language Pathology,
Telehealth
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telecommunications technology to deliver clinical services at
a distance by linking clinician to client, caregiver, or any
person(s) responsible for delivering care to the client, for the
purposes of assessment, intervention, consultation and/or
supervision” (SPA, 2014, p. 4). The governing body of the
SLP profession, Speech Pathology Australia (SPA),
supports and encourages the use of telehealth but
recommends that the services provided through this service
delivery model be “equivalent to standard clinical care”
(SPA, 2014).
Telehealth-delivered SLP services have previously
been investigated in reviews regarding a number of practice
areas and populations. Mashima and Doarn (2008)
conducted an extensive literature review on the application
of telehealth in SLP with adults and a small number of
studies with children. They reviewed 40 studies investigating
disorders relating to adult neurogenic communication,
fluency, voice, dysphagia (n=35), and childhood speech and
language (n=5). This review suggested that telehealth is a
feasible and effective method for providing SLP services at
a distance. However, the authors noted that the reviewed
literature consisted primarily of pilot studies and anecdotal
accounts of telehealth applications rather than large, well-
controlled, randomised clinical trials (Mashima & Doarn,
2008). Reynolds, Vick, and Haak (2009) conducted a
narrative review of 29 studies which were analysed using a
quality assessment checklist. These 29 articles focused on
assessment and intervention with the adult (n=19) and
paediatric (n=7) population as well as an unspecified
population (n=3). The authors concluded that the results
achieved through the telehealth and in-person service
delivery models were equivalent; however, many of the
studies noted that telehealth was not a complete
replacement for in-person services but may be appropriate
for combined practices. These findings were consistent with
the review conducted by Theodoros (2012), which
investigated 19 studies regarding adult neurogenic
communication, voice, stuttering, dysphagia and
laryngectomy follow-up and four studies regarding paediatric
speech, language and literacy disorders. Edwards, Stredler-
Brown, and Houston (2012) conducted a further review
investigating 39 studies in the fields of audiology and SLP.
The majority of these studies were conducted on adult
populations (n=27) with neurogenic communication, voice,
dysphagia and fluency disorders. The review was further
expanded to include a small number of studies (n=12)
focusing on early intervention services. This review by
Edwards et al. (2012) suggested that telehealth is an
effective way to diagnose and treat both adults and children
in the areas investigated, as services provided through
telehealth or by conventional in-person means resulted in
similar outcomes.
Although these previously conducted reviews included
studies targeting the paediatric population, the number of
studies investigated was minimal and the focus was
primarily on the application of telehealth in SLP with the
adult population. These reviews suggest positive results.
However, service delivery models and intervention
techniques used with children typically differ from those
used with adults, as the focus with children tends to be on
achieving developmental milestones, as opposed to a
rehabilitative approach that is commonly used with adults
(Edwards et al., 2012). It can therefore be difficult to apply
previous findings that were obtained from primarily adult-
focussed studies to the paediatric population.
The potentially detrimental effects of communication
difficulties on a child’s education and social participation
increase the importance of alleviating these where possible,
regardless of where the child resides. It is therefore
important to focus on this specific population to determine
whether telehealth service delivery may be a viable
alternative to in-person intervention in locations where this
service is not readily available. However, no review to date
has focused specifically on evaluating the telehealth studies
undertaken with children. Thus, this systematic review
evaluated the present literature to determine if telehealth-
delivered SLP interventions are as effective as traditional in-
person delivery for primary school-age children with speech
and/or language difficulties.
METHODS
To address this study’s aim, a systematic review was
conducted in accordance with the Preferred Reporting Items
for Systematic reviews and Meta-Analyses (PRISMA)
guidelines (Liberati et al., 2009). The PRISMA flow chart is
detailed in Figure 1 (adapted from Liberati et al. (2009)). The
current systematic review was registered with the
PROSPERO registry: CRD42016052187.
SEARCH STRATEGY
A systematic literature search was undertaken using the
PubMed, CINAHL, Scopus, ERIC and SpeechBITE
databases. Additional manual searches in two highly
relevant journals, the International Journal of Speech-
Language Pathology and the International Journal of
Telerehabilitation, were also conducted, in order to locate
more recent versions of journals that may not yet have been
transferred into the databases. Systematic search strategies
were adhered to using the following search string:
(telehealth OR telepractice OR telerehabilitation OR
teletherapy) AND (speech pathology OR speech-language
pathology OR speech therapy) AND (child OR paediatric). In
addition, citations and references within identified articles
were searched for further studies relevant to the review. The
authors corresponded with experts in the field to ensure all
relevant studies were included within the review.
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STUDY SELECTION
The studies identified through the systematic searches
were included in the review if they reported studies of
speech and language intervention delivered through
telehealth to primary school-age children (4-12 years)
across various settings (e.g., schools, private practice),
provided treatment outcome data on intervention
effectiveness and did not describe special client populations
(e.g., autism spectrum disorder, childhood apraxia of
speech). The year of publication was not restricted, ensuring
all available evidence was identified, but the search was
limited to articles written in English. Papers were included
on speech intervention (speech sound production and
intelligibility) and language intervention (receptive and
expressive language). Articles describing voice, fluency,
pragmatics, literacy or special client populations were
excluded to focus on primary speech and language
disorders.
DATA EXTRACTION
All articles identified from the initial searches were
reviewed and duplicates were removed. The title and
abstracts of the articles were screened for inclusion by all
authors, with the remaining articles reviewed in full text and
the exclusion criteria applied. In the case of disparities
between the authors’ judgments regarding suitability, they
consulted to achieve agreement. Data from the included
studies were extracted using a standard table developed
specifically for this review (refer to Appendix A). The articles
were summarised in terms of intervention type and
participants, study aim and design, equipment, methods and
main study results.
RESULTS
The initial database and reference list searches
conducted during November and December 2016 yielded a
total of 120 unique articles. During the initial screening, 68
articles were excluded on title and another 33 articles were
eliminated on abstract. The remaining 19 articles were
reviewed in full-text. The full-length review excluded a
further 12 articles, because they: (1) did not describe
speech and language intervention via telehealth with the
majority of participants between 4 and 12 years of age,
and/or (2) did not provide outcome data on intervention
effectiveness. From this selection process, seven articles
were retained for the final systematic review. The review
process is detailed in the flow chart in Figure 1.
STUDY DESIGN
The seven included studies focused on telehealth-
delivered speech and language intervention with primary
school-age children. Two of the included studies were
randomised controlled trials (level of evidence II) (Grogan-
Johnson, Alvares, Rowan, & Creaghead, 2010; Grogan-
Johnson et al., 2013) and another two studies were method
comparison studies (level of evidence IIIa) (Gabel, Grogan-
Johnson, Alvares, Bechstein, & Taylor, 2013; Grogan-
Johnson et al., 2011) which were investigating the validity of
telehealth-delivered intervention by comparing it with in-
person results. A further three studies used a pre versus
post study design (level of evidence IV) to determine if
telehealth-delivered intervention facilitated improvement in
the participants’ communication skills, with no comparison
group (Fairweather, Lincoln, & Ramsden, 2016; Isaki &
Farrell, 2015; Jessiman, 2003). Four of these papers
included a participant satisfaction survey (Fairweather et al.,
2016; Grogan-Johnson et al., 2010; Isaki & Farrell, 2015;
Jessiman, 2003). Only one of the seven studies was
conducted in Australia (Fairweather et al., 2016). The
intervention services provided within the included studies
were undertaken within a structured school/university clinic
(n=6) or community health clinic (n=1) environment. The
studies varied according to the intervention focus and
outcome measures used.
PARTICIPANTS
The majority of the studies (71%) focused only on
primary school-age children between the ages of 4 and 12
years (Fairweather et al., 2016; Gabel et al., 2013; Grogan-
Johnson et al., 2010; Grogan-Johnson et al., 2011; Grogan-
Johnson et al., 2013; Isaki & Farrell, 2015; Jessiman, 2003).
However, one study included a very small number of
participants from 3 years of age (exact number of
participants not specified) (Fairweather et al., 2016) and
another included one participant aged 15 years (Gabel et
al., 2013). Although these few participants were aged
outside of the set criteria, the majority of the participants in
the studies were aged between 4 and 12 years, allowing the
results to be suitably applied to the primary school-age
population. Other studies however were excluded during the
initial study selection process due to the majority of
participants being aged outside of the set criteria. Five of the
seven studies (Fairweather et al., 2016; Grogan-Johnson et
al., 2011; Grogan-Johnson et al., 2013; Isaki & Farrell, 2015;
Jessiman, 2003) had small sample sizes (2 to 19) and the
remainder had moderate sample sizes ranging from 38 to 71
participants.
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Figure 1. PRISMA Flow Chart showing search and selection process that yielded the final seven articles (adapted from
Preferred Reporting Items for Systematic reviews and Meta-Analyses [PRISMA]; Liberati et al., 2009). Note. From Moher D,
Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009) Preferred Reporting Items for Systematic Reviews and Meta-
Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. https://doi.org/10.1371/journal.pmed.1000097
TELEHEALTH EQUIPMENT
Three papers reported the use of commercial
videoconferencing systems (Gabel et al., 2013; Grogan-
Johnson et al., 2011; Grogan-Johnson et al., 2013)
designed for use with low-speed connections (using a 128
kbit/s internet link). In contrast, three studies reported the
use of web-based videoconferencing platforms (Fairweather
et al., 2016; Grogan-Johnson et al., 2010; Isaki & Farrell,
2015) and the final study used a custom telehealth
videoconferencing system (Jessiman, 2003). Two studies
complemented their telehealth equipment with document
cameras (Grogan-Johnson et al., 2010; Jessiman, 2003).
The seven reviewed studies used real-time
videoconferencing.
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INTERVENTION TYPE, INTENSITY AND
TARGETS
Five of the seven included studies investigated the
application of both speech sound and language intervention
through telehealth (Fairweather et al., 2016; Gabel et al.,
2013; Grogan-Johnson et al., 2010; Isaki & Farrell, 2015;
Jessiman, 2003). The remaining two studies focused
primarily on the investigation of speech sound intervention
(Grogan-Johnson et al., 2011; Grogan-Johnson et al.,
2013). Notably, no studies included in the review solely
examined the provision of language intervention through
telehealth.
SPEECH SOUND INTERVENTION
Two studies conducted only traditional speech sound
intervention (Van Riper approach to articulation intervention)
through both telehealth and in-person delivery models. The
participants in the study conducted by Grogan-Johnson et
al. (2011) received 20 minutes of therapy each week
between fall (baseline) and spring (post-intervention),
whereas Grogan-Johnson et al. (2013) provided intervention
for 30 minutes twice per week for a five week period. Both
studies followed the same session format, however, only
one study required the participants to reach a set number of
productions prior to progressing through the intervention
levels (Grogan-Johnson et al., 2013). The intervention
targets in both studies were selected based on the
participant’s current Individualised Education Plan (IEP)
goals, with the Grogan-Johnson et al. (2013) study also
selecting additional targets based on the results of pre-
testing on the Goldman Fristoe Test of Articulation – second
edition (GFTA-2) (Goldman & Fristoe, 2002).
COMBINED SPEECH AND LANGUAGE
INTERVENTION
An examination of a combination of speech sound and
language interventions was conducted in five of the seven
studies. The duration of intervention varied between studies.
Participants in the study by Fairweather et al. (2016)
received six 30 minute sessions on a fortnightly basis over a
12 week period, whilst Jessiman (2003) provided hourly
treatment sessions twice a week for two months and Isaki
and Farrell (2015) provided weekly therapy for two blocks of
15 weeks. Grogan-Johnson et al. (2010) provided one group
of participants with telehealth treatment for four months
followed by in-person intervention for another four months,
while the second group received in-person intervention for
four months and then subsequently telehealth-delivered
intervention for four months. Further detail regarding the
number and frequency of sessions in this study was not
provided. Gabel et al. (2013) provided intervention to the
telehealth group for 20 minutes per week for one academic
year.
Further differences between the studies focussing on
both speech and language intervention related to whether or
not the treatment sessions were provided on an individual
basis or in a group setting. An individual format was adopted
in three of the studies (Fairweather et al., 2016; Isaki &
Farrell, 2015; Jessiman, 2003), however, in the remaining
two studies, the participants in the telehealth groups
received mainly individual therapy sessions with some small
group sessions also conducted (Gabel et al., 2013; Grogan-
Johnson et al., 2010). The in-person participants in these
two studies received primarily group sessions with 2-4
students, with some students alternatively receiving an
individual pull-out model of intervention (Gabel et al., 2013;
Grogan-Johnson et al., 2010).
The intervention provided varied depending on the
selected targets. Two studies selected intervention targets
based on the participant’s IEP goals and objectives (Gabel
et al., 2013; Grogan-Johnson et al., 2010), whereas another
two studies established therapy goals based on recent
assessment results (Isaki & Farrell, 2015; Jessiman, 2003).
The fifth study developed goals in collaboration with adults
familiar with each participant (Fairweather et al., 2016).
OUTCOME MEASURES
The included studies examined the efficacy of
telehealth intervention using various outcome measures. Six
different outcome measures were investigated: the Goldman
Fristoe Test of Articulation – second edition (GFTA-2);
Functional Communication Measures (FCMs); goal
achievement; informal probes; comparison of pre-
intervention baselines with post-intervention production
levels; and change reported on quarterly progress reports.
EFFICACY OF THERAPY
GOLDMAN FRISTOE TEST OF
ARTICULATION – SECOND EDITION (GFTA-
2)
Three studies utilised pre- and post-intervention testing
with the GFTA-2 to compare telehealth to in-person
delivered intervention (Grogan-Johnson et al., 2010;
Grogan-Johnson et al., 2011; Grogan-Johnson et al., 2013).
Each of these studies revealed no significant difference
between the two treatment modalities, with the first study
reporting across three measurement points (pre-test p=0.16;
post-first treatment period p=0.06; post-second treatment
period p=0.21) and the second and third study reporting
across two measurement points each (pre-test p=0.805;
post-test p=0.805; and pre-test p=0.706; post-test p=0.644,
respectively). Using a repeated measure ANOVA, Grogan-
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Johnson et al. (2013) found no significant difference
between the two groups on post-intervention GFTA-2 testing
(p=0.415); however, a statistically significant change in test
scores was evident from pre- to post-intervention for both
groups (p=0.020), indicating that both groups made
significant and similar progress during intervention. Grogan-
Johnson et al. (2011) identified a similar result with both
groups making significant improvement in performance
(p=0.014) but neither group was found to improve more than
the other.
FUNCTIONAL COMMUNICATION
MEASURES (FCMS)
Two studies measured outcomes through Functional
Communication Measures (FCMs), which are used as a
measure of progress in the ASHA K-12 Schools National
Outcomes Measurement System (NOMS) database
(American Speech-Language-Hearing Association, 2003;
Gabel et al., 2013; Grogan-Johnson et al., 2010). This
database reports descriptive information on students
receiving in-person speech-language intervention in the
school system. Gabel et al. (2013) compared their results for
the telehealth condition with the subjects reported in the
NOMS database (in-person participants). This study
revealed similarities between the changes in FCM level for
the telehealth group and also the in-person participants for
disorders related to intelligibility (66.7% improved at least
one level in telehealth and 62.3% in-person) and speech
sound production (84.6% in telehealth and 78.4% in-person)
(Gabel et al., 2013). For spoken language production, this
study revealed a sizable difference between telehealth and
in-person results, with 55.6% and 71.1% improving at least
one level respectively. Gabel et al. (2013)’s results for
spoken language comprehension were varied, with a higher
percentage of telehealth participants improving by one level
(47.1% vs. 38.2%) and a lower percentage improving by
multiple levels in comparison to the in-person group (11.8%
vs. 27.8%). The results reported by Gabel et al. (2013) were
in contradiction to the results identified by Grogan-Johnson
et al. (2010). As part of this research, the FCMs were used
to compare progress between two groups of students, one
group that received telehealth-delivered intervention and the
other via in-person. This study found that a slightly lower
percentage of participants in the telehealth group improved
at least one level compared to the in-person group for
disorders related to intelligibility (63% vs. 70%, respectively).
This was similar for the speech sound production measure,
with less participants in the telehealth group improving at
least one level (71% telehealth vs. 79% in-person).
However, for disorders related to spoken language
production, a higher percentage of telehealth participants
improved by a minimum of one level in comparison to the in-
person group (72% vs. 62%, respectively).
The results of these two studies demonstrate conflicting
findings; however, neither of the studies conducted
statistical analyses of the results and thus the significance of
the percentage differences between the two intervention
conditions is unknown. The limitations evident in both
studies could also likely have introduced confounding
factors, which may have affected the results. For instance,
one study had a considerable difference in the sample size
for the two conditions and did not randomly allocate
participants, but instead selected the telehealth participants
from a pilot project already being conducted (Gabel et al.,
2013). The selected participants were allocated to the
telehealth condition and their results were compared with
data already stored in the NOMS database, therefore
introducing potential bias. Neither of the studies controlled
for the type of service utilised (e.g., individual or group
therapy) or the methods of treatment provided (Gabel et al.,
2013; Grogan-Johnson et al., 2010).
GOAL ACHIEVEMENT
Two studies (Fairweather et al., 2016; Isaki & Farrell,
2015) used goal achievement to determine outcomes, with
one study using Goal Attainment Scaling (GAS), a criterion-
referenced measure of change rated on a five-point scale, to
evaluate the telehealth program (Fairweather et al., 2016).
This study revealed that 68.9% of the established goals
were achieved at either an expected or greater than
expected level. From the 19 participants, 15 (78.9%)
achieved at least one goal at or above the expected level
and eight participants (42.1%) achieved all their goals. The
GAS scores were converted to t-scores to reflect
performance above or below the expected level (e.g.,
achieving the set goal). This analysis revealed that 73.68%
of the participants achieved or exceeded their set goal
following six telehealth sessions.
The second study evaluated goal completion against a
set criterion (Isaki & Farrell, 2015), with the results indicating
that for the speech goals targeted, three of the five
participants achieved 100%, one achieved 50% and the
other achieved 33%. The three participants with language
goals all achieved 100%. These results related only to
telehealth and did not provide a comparison to in-person
treatment.
INFORMAL PROBES
Examination of progress using informal probes was
conducted in one study (Jessiman, 2003). The participants’
goals or number of goals were not detailed, however, based
on informal probes completed after therapy and by parent
report it was suggested that the participants made progress
in their speech and language goals across the 12 sessions.
One participant was reported to have made “substantial”
progress while the other participant’s progress was “less
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substantial, but still appeared promising” (Jessiman, 2003,
p.48-49). Jessiman (2003) quantified the participant’s
progress using these terms by determining the number of
speech and language skills mastered or progressing within
the treatment period.
COMPARISON OF PRE-INTERVENTION
BASELINES WITH POST-INTERVENTION
PRODUCTION LEVELS
Two studies used the comparison of pre-intervention
baselines with post-intervention production levels as an
outcome measure (Grogan-Johnson et al., 2011; Grogan-
Johnson et al., 2013). The analysis of this outcome measure
differed between the two studies, however both studies
indicated that progress was achieved regardless of the
treatment modality. Grogan-Johnson et al. (2011) measured
the change in speech sound production from baseline to the
completion of intervention, with the results suggesting that
both the telehealth (n=55) and in-person (n=8) groups made
similar amounts of progress. The results were comparable
for the percentage of improved baselines, with 98% (n=54)
in the telehealth and 95% (n=6) in the in-person group.
However, the in-person group had a higher percentage of
unchanged baselines (2% [n=1] for telehealth and 12.5%
[n=1] for in-person) and decreased baselines (0% [n=0] for
telehealth and 12.5% [n=1] in-person) (Grogan-Johnson et
al., 2011). The varying number of baselines targeted in the
intervention may explain the difference in the results for
unchanged and decreased baselines between the telehealth
and in-person methods in this study. There were 55
baselines targeted for participants in the telehealth group
and only eight collected for the in-person participants. Both
groups only had one unchanged baseline however, due to
the high variance in total baselines targeted, a considerable
difference in percentage was indicated.
Grogan-Johnson et al. (2013) used listener judgments
to compare pre- and post-intervention productions and these
results were examined using a repeated measures ANOVA.
The listener judgments revealed a statistically significant
difference across time for both groups (p=0.007), but no
significant difference between the two groups in regard to
the amount of change across time (p=0.434). Thus, both
groups were deemed to receive benefit from the intervention
regardless of the service delivery model.
QUARTERLY PROGRESS REPORTS
The results reported on participants’ quarterly progress
reports were used as outcome measures for two studies
(Grogan-Johnson et al., 2010; Grogan-Johnson et al.,
2011). In the study by Grogan-Johnson et al. (2010),
quarterly student progress reports after the first treatment
period identified that adequate progress or mastery was
achieved for 75% (n=58 for telepractice and n=34 for in-
person) of objectives in both conditions. A significant
difference (p<0.05) between the two intervention conditions
was indicated following the second treatment period, with
mastery or adequate progress achieved for 88% (n=42) of
objectives in the telehealth model and 84% (n=56) of
objectives in the in-person model. A similar result was found
in Grogan-Johnson et al. (2011)’s study, as more
participants in the telehealth group (100%, n=25) mastered
or made adequate progress on their IEP goals in
comparison to the 87% (n=13) of participants in the in-
person group.
The difference in the results for the number of IEP goals
achieved between the intervention conditions in these
studies can be explained by a disproportionate number of
IEP objectives being targeted in the two intervention
conditions and across the first (telehealth n=77, in-person
n=45) and second treatment period (telehealth n=48, in-
person n=67). A larger number of total IEP objectives were
targeted in the telehealth group across the two treatment
periods.
PARTICIPANT SATISFACTION
Four studies reported satisfaction data through the
provision of surveys (Fairweather et al., 2016; Grogan-
Johnson et al., 2010; Isaki & Farrell, 2015; Jessiman, 2003).
High levels of satisfaction with telehealth-delivered
intervention and the progress achieved were found in all
studies. Two studies reported that concerns were identified
regarding the child’s reduced attention in telehealth sessions
(Isaki & Farrell, 2015) as well as the need to improve
internet connectivity, audio output and communication with
stakeholders (Fairweather et al., 2016).
DISCUSSION
The present review investigated the efficacy of
telehealth-delivered SLP services when compared to
traditional in-person delivery for primary school-age children
with speech and/or language difficulties. Evidence was
collated through a systematic review of the available
telehealth literature. Overall, the findings of the review
showed that there is some evidence to support the use of
telehealth when delivering SLP intervention services to
school-age children. However, it also demonstrated that the
amount of research into speech and language intervention
for children via the telehealth service delivery model is
limited and of variable quality, as the included studies span
across the levels of evidence according to the National
Health and Medical Research Council (NHMRC) (Australian
Government: National Health and Medical Research
Council, 2009).
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A total of six different types of outcome measures were
used to investigate the efficacy of telehealth intervention,
therefore creating difficulty in directly comparing the studies.
The design of the three studies using the goal achievement
and informal probe outcome measures did not allow direct
comparison between the telehealth and in-person
intervention conditions, as the study designs only evaluated
the telehealth-delivered intervention, without comparing it to
the traditional in-person model (Fairweather et al., 2016;
Isaki & Farrell, 2015; Jessiman, 2003). However, these
measures demonstrated considerable progress based on
the targeted goals during the telehealth intervention.
The remaining reviewed studies directly compared the
telehealth and in-person intervention conditions using four
different outcome measures. There was convincing
evidence in the literature suggesting that speech sound
intervention delivered through telehealth to primary school-
age children was just as effective as in-person intervention
when measured through the GFTA-2 (Grogan-Johnson et
al., 2010; Grogan-Johnson et al., 2011; Grogan-Johnson et
al., 2013). Participants in both intervention conditions made
significant improvements in performance and equal gains
were demonstrated on the post-intervention testing.
Positive results were also identified in the studies that
used the comparison of pre-intervention baselines and post-
intervention production levels to measure outcomes, with
both studies indicating that progress was achieved
regardless of the treatment modality (Grogan-Johnson et al.,
2011; Grogan-Johnson et al., 2013).
Despite these positive results, the two studies that
examined telehealth-delivered speech and language
intervention and used the FCMs as their outcome measure
identified contradictory results. For the intelligibility and
speech sound production measures, Gabel et al. (2013)
found that more participants improved in the telehealth
condition whereas, in the study by Grogan-Johnson et al.
(2010), a lower percentage of participants improved in the
telehealth condition when compared to the in-person
condition, using the same measures. For the spoken
language production measure, Gabel et al. (2010) found that
a much lower percentage of participants improved in the
telehealth condition compared to the in-person condition;
however, Grogan-Johnson et al. (2010) found that more
participants improved in the telehealth condition, again using
the same measure. The authors did not conduct statistical
analyses of these results, making it difficult to determine if
the difference between the results is significant.
Both speech sound and language interventions were
implemented as part of the seven studies included in the
review. However, of these reviewed studies, there appeared
to be a stronger focus on speech sound intervention, with
two studies primarily aiming to assess this range of practice
area through telehealth. The remaining five studies
investigated the application of both speech sound and
language intervention through telehealth, however two
focused more heavily on speech than on language, as a
greater number of speech goals were targeted in one study
(Isaki & Farrell, 2015) and more speech-based FCMs were
used as an outcome measure in another study (Grogan-
Johnson et al., 2010). Overall, whilst the studies revealed
that intervention delivered through telehealth is as effective
as in-person intervention, this result seemed to be found
more consistently with the provision of speech sound
intervention than with language intervention. Although this
suggests that speech sound intervention may be more
suited to a telehealth approach, this finding is likely to be
skewed by the more predominant focus on this range of
practice area in the reviewed studies. Another possible
explanation for this result is the difficulty in identifying
comprehensive measures of language to be used when
conducting research relating to telehealth-delivered
services, as language is such a broad and highly variable
range of practice area.
The uptake of the use of telehealth by speech-language
pathologists has been influenced by the need to address the
inequity of access to services experienced by Australia’s
rural population (SPA, 2014). Telehealth allows services to
be delivered to clients, including children, within their home
and with the assistance of parents/carers, regardless of their
location. The majority of the studies included in this review
were however undertaken within a structured school or clinic
environment, with little or no parent involvement. This
results in difficulty drawing conclusions about the
effectiveness of telehealth when implemented in the home
setting, where the environment is likely to be less structured
and full parent involvement is required.
Interestingly, all of the reviewed studies utilised real-
time videoconferencing facilities, allowing the clinician and
client to visualise each other. This finding is consistent with
results from previous reviews (Mashima & Doarn, 2008;
Reynolds et al., 2009; Taylor, Armfield, Dodrill, & Smith,
2014), indicating that real-time interactions support the
delivery of services and strongly influence the clinical
outcomes achieved through telehealth. Delivering speech
and language intervention services through real-time
videoconferencing facilities is an effective method of service
delivery as this medium most closely resembles in-person
interactions through the transmission of auditory and visual
signals at a distance (Mashima & Doarn, 2008; Reynolds et
al., 2009). SLP practice primarily consists of auditory, verbal
and visual interactions, therefore allowing services to be
easily translated into technology-based environments
(Theodoros, 2012). This level of connection enhances the
sense of clinician presence and facilitates the development
of rapport between clinicians, clients and their families,
provided that the necessary bandwidth is available to
support the process (Mashima & Doarn, 2008; Reynolds et
al., 2009).
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Reports that videoconferencing facilities do effectively
support real-time interactions between clinicians, clients and
families, are consistent with parent, student, and staff
satisfaction data that was collected as part of four of the
seven studies included in this review (Fairweather et al.,
2016; Grogan-Johnson et al., 2010; Isaki & Farrell, 2015;
Jessiman, 2003). Satisfaction ratings were high across all
stakeholders surveyed despite the concerns raised
regarding slightly reduced attention by children in telehealth
sessions and difficulties with technology. Similar findings
with stakeholder satisfaction have been reported in various
studies and reviews (Constantinescu et al., 2014; Crutchley
& Campbell, 2010; Lincoln, Hines, Fairweather, Ramsden, &
Martinovich, 2015; Mashima & Doarn, 2008; Sicotte,
Lehoux, Fortier-Blanc, & Leblanc, 2003), indicating that
relevant stakeholders deem telehealth as an effective
method of delivering speech and language intervention to
children. It is however, important to note that satisfaction
ratings related to telehealth are likely to be particularly high
in rural areas where in-person SLP services are not typically
available.
Overall, the findings from the seven reviewed studies
revealed that telehealth is a promising method for treating
children with speech and/or language difficulties. However,
in spite of this interesting finding, a number of
methodological issues limit the quality of the results. The
conclusions found in the literature on the effectiveness of
telehealth-delivered intervention are dependent on the
selected outcome measure. Outcomes for telehealth were
more consistently positive when standardised assessments,
such as the GFTA-2, were used for the pre- and post-
intervention testing. The literature also revealed
considerable variation in the intensity of therapy, with some
studies claiming significant improvement after only a small
number of sessions (6) were delivered fortnightly
(Fairweather et al., 2016), whereas others reported on a
larger number of sessions (10-12) that were delivered twice
weekly (Grogan-Johnson et al., 2013; Jessiman, 2003),
making the intervention format more intense. Additionally,
the majority of the studies reviewed were based on a small
and unequal sample size, resulting in difficulty generalising
the results. Furthermore, of the four studies comparing the
service delivery models, two studies did not randomly
allocate participants to the intervention conditions, therefore
introducing potential intervention condition bias. These
differences in the studies made direct comparison difficult
and therefore, may limit the weight of the findings. Thus, to
provide further evidence regarding the effectiveness of
telehealth-delivered intervention, studies that use more
rigorous methods, such as randomisation of participants and
power calculations, need to be performed to ensure that
potential key findings can be accurately identified.
The current systematic review also has some limitations
that require consideration. Firstly, although two studies
included a very small number of participants outside the set
age criteria, the primary school-age population was the
focus of the review. Therefore, studies which included a
large number of children outside this age range were
excluded due to the differences in attention span and
behaviour between age groups (Owens, 2012). Whilst this
allows the results of the review to be appropriately applied to
the primary school-age population, without the data being
skewed from a mix of different populations, further research
in this area is required to confirm if telehealth is as effective
as in-person intervention when delivered in an early
intervention format or to adolescents. Furthermore, the
majority of the studies included in the review were
undertaken in the USA, thus generalisability of the results to
rural and remote communities within Australia is limited, due
to factors such as the frequent lack of adequate and reliable
internet connectivity (Australian Bureau of Statistics, 2016;
Erdiaw-Kwasie & Alam, 2016; Park et al., 2015). Therefore,
rural Australian communities may have difficulty supporting
the telehealth service delivery model, an issue that may not
have been adequately captured in this review.
CONCLUSIONS
The current review aimed to determine if telehealth-
delivered SLP interventions are as effective as traditional in-
person delivery for primary school-age children with speech
and language difficulties. The reviewed research was limited
and of variable quality, however, the evidence presented
showed that telehealth is a promising service delivery
method for delivering speech and language intervention
services to this population. This alternative service delivery
model has the potential to improve access to SLP services
for children living in geographically remote areas, reducing
travel time and alleviating the detrimental effects of
communication difficulties on education, social participation
and employment. Although some initial positive findings
have been published, there is a need for further research
using more rigorous study designs to further investigate the
efficacy of telehealth-delivered speech and language
intervention.
ACKNOWLEDGMENTS
The first author gratefully acknowledges Leisa Skinner,
Dr Melanie Hayman, Professor Michelle Lincoln and
Associate Professor Tania Signal for their assistance in the
preparation of this article. This research was supported by a
CQUniversity Summer Research Scholarship.
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DECLARATION OF INTEREST
The authors report no declarations of interest. The
authors alone are responsible for the content and writing of
the paper.
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APPENDIX A
Table 1. Characteristics of Studies Identified in the Systematic Review
Study
Intervention and
Participants
Study Aim
Methods
Results/Outcome
Fairweather
et al.
2016
Australia
Intervention targeting
speech sounds,
receptive/expressive
language, pragmatics
and phonological
awareness.
N=19, average age 7.8
years (range 3-12yrs).
Four SLPs
To investigate the
effectiveness,
feasibility and
acceptability of a
SLP teletherapy
(TH) program for
children in rural
and remote areas.
Study Design: Pre/post
design, reporting on degree
of progress in TH tx as noted
by GAS results.
Equipment: Webcam
enabled laptops, desktop
computers or iPads, 1 of 3
low-bandwidth VC platforms
(Adobe, Facetime or Skype),
headsets and microphones
Procedure: GAS goals
developed in collaboration
with supporting adults in
child’s local environment.
Participants received 6x
30mins SLP teletherapy
sessions on a fortnightly
basis using Come N See
(CNS) program over a 12-
week period. Semi-structured
interviews conducted with
parents four weeks prior to
the conclusion of the
sessions.
31 goals (68.9%) were
achieved at either an
expected or greater than
expected level. Of the 19
participants, 15 (78.9%)
achieved at least one
goal at the expected
level or beyond. 8
children (42.1%)
achieved all goals.
T-scores revealed
73.68% of the
participants achieved at
or above the expected
level after up to 6 30-
minute teletherapy
sessions.
Parents felt telehealth
intervention was feasible
but engagement and
acceptability would be
improved with regular
communication between
stakeholders.
Gabel et al.
2013
USA
Speech & language Tx
Children. Grade – K-12
Telepractice group
N=71, 63.4%M/
36.6%F. Age 5-15 yrs.
NOMS database group
- N=5332, 67%M and
33%F
Three SLPs
To study the
effectiveness of a
telepractice SLP
program for
school-age
children by
comparing data
from a student
sample receiving
telehealth
intervention with
data from direct,
in-person services
Study Design: Method
comparison study, reporting
on level of progress based on
FCM scores.
Equipment: Polycom
videoconferencing software,
desktop computers, webcam
with built-in microphone,
headsets, 128kbit/s internet
link.
Procedure: Participants in
TH-led condition were
compared to data from direct,
in-person services available
from the ASHA K-12 National
Outcomes Measurement
System (NOMS) database.
Outcome data measured
through FCMs. Participants in
70% of telepractice
participants progressed
one or more levels of the
FCMs.
Improvement varied
across difficulties
studied, but best
outcomes identified for
intelligibility and speech
sound production
intervention. Data
compared favourably
with NOMs database for
same intervention.
Data from telepractice
participants receiving
spoken language
comprehension and
production information
differed from NOMs
database with a higher
percentage of
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telepractice group received
20 minutes of therapy weekly.
participants making no
progress and a lower
percentage progressing
multiple levels.
Grogan-
Johnson et
al.
2010
USA
Intervention for spoken
language production,
speech sound
production and/or
intelligibility.
N=38 (13F, 25M). Age
range 4-12 years.
Group 1 - N= 17
Group 2 - N = 17
Four SLPs
To investigate the
results of speech
language therapy
provided through
TH compared to
in-person tx.
Study Design: Single subject
time-series (A-B) repeated
measures design, reporting
comparison across
measurements taken at three
points in time (beginning,
middle and end of project).
Equipment: Computer-based
videoconferencing,
headphones and a document
camera.
Procedure: Participants were
treated in two groups – group
1 received TH tx for 4 months
and then subsequently in-
person therapy for 4 months.
Group 2 received in-person
therapy for 4 months, then
TH therapy for 4 months.
Participants were randomly
allocated to the groups.
Outcome measures were
student progress on GFTA-2
and NOMS database,
participant satisfaction and
any interruptions to service
delivery.
No significant difference
in GFTA-2 scores
between participants in
the two treatment groups
at pre-test (p=0.16);
following the first
treatment period
(p=0.06) and second
treatment period
(p=0.21).
Student progress reports
after the first tx period
identified that adequate
progress or mastery was
achieved for 75% of
objectives in both
conditions. Following
second tx period mastery
or adequate progress
was achieved for 88% of
objectives in TH and
84% of objectives for the
in-person model –
significant difference
(p=<0.05).
All participants
expressed a high
satisfaction with the
delivery of services,
progress achieved,
comparison with in-
person intervention and
general attitude towards
TH.
Grogan-
Johnson et
al.
2011
USA
Speech sound disorder
intervention
N=13 (11M, 2F).
Age=6-11yrs. All
children with a speech
sound disorder.
Telehealth group –
N=7
In-person group – N=6
Two SLPs
To examine
whether speech
intervention using
computer-based
materials with
school-age
students via
telehealth is
comparable to
services delivered
via a in-person
SLP.
Study Design: Method
comparison study, reporting
statistical difference between
TH and in-person conditions.
Equipment: Desktop
computer, webcam with
microphone and headset.
custom TH system with real-
time VC with 128kbit/s
internet link and TinyEYE
Speech Therapy software.
Procedure: Both groups
received traditional speech
sound intervention for 20
minutes weekly. Multiple
measures of progress
assessed: 1) Pre- and post-
testing using GFTA-2; 2)
comparison of pre-
intervention baselines with
No significant difference
between the TH and in-
person groups on the
pre- (p = 0.805) and
post-tests (p = 0.805).
Both groups had a
significant improvement
in performance (p =
0.14).
Children in both SDMs
improved significantly in
their speech production
with the telehealth
students demonstrating
greater IEP goal
mastery.
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production levels post-
intervention; and, 3)
comparison of quarterly
progress reports.
Grogan-
Johnson et
al.
2013
USA
Speech sound therapy
N=14.
Telepractice group:
N=7, Avg age=8.4yrs,
range= 6.4-9.9yrs
Side-by-side group:
N=7, avg age=9yrs,
range= 7.9-10yrs
Two SLPs
To investigate
telehealth-
delivered
intervention
services by
comparing speech
sound intervention
delivered to
children in either a
telepractice or in-
person delivery
model in an
intervention
program.
Study Design: Method
comparison study, reporting
statistical difference between
TH and in-person conditions.
Equipment: Laptop, web-
camera with microphone and
headset. Polycom VC system
with 128kbit/s internet link.
Procedure: Both groups
received traditional speech
sound intervention for 30
minutes twice per week for a
5-week period. Participants
were randomly assigned to
either the in-person or TH
condition. Multiple measures
of progress assessed: 1) pre-
and post-intervention testing
conducted using subtests of
GFTA-2; and 2) pre-and post-
recording of single word
identification task.
No significant difference
found between two
groups on post-
intervention GFTA-2
through repeated
measures ANOVA
(p=0.415).
No statistically significant
difference between the
mean listener
judgements for the two
groups on the pre-test
(p=0.160) but a
statistically significant
difference in mean
listener judgements
across time for both
groups (p=0.007). Thus,
both groups benefitted
from intervention and
that benefit was the
same regardless of
intervention condition.
Isaki et al.
2015
USA
Speech and/or
language intervention
Child participants –
N=5. Mean age 7.1yrs
(range 4.5-9.8 yrs)
Adult participants –(not
reported in review)
To evaluate the
effectiveness of
Apple iPads to
deliver telepractice
speech and/or
language services.
Study Design: Pre/post
design, reporting on degree
of progress in TH tx as noted
by achievement of goals.
Equipment: Apple iPads with
Facetime.
Procedure: All participants
received individual
telepractice therapy for a total
of 15 weeks per academic
semester. Sessions were
provided weekly for 30-45
minutes.
Participants met the
majority of their therapy
goals with the paediatric
participants meeting at
least 33% of the speech
goals and 100% of the
language goals.
Satisfaction surveys
revealed no significant
change of opinions about
telehealth following the
intervention (p>0.05).
Clinicians indicated the
need to resolve technical
problems with use of
iPads.
Jessiman
2003
USA
Speech sound therapy
and improving
understanding and use
of language forms
(noun and verb forms,
& linguistic concepts)
Field report
providing
preliminary
information on the
use of the TH
technology in the
provision of
speech and
language
assessment and
Study Design: Pre/post
design, reporting agreement
between TH and in-person
conditions for assessment
and degree of progress in TH
intervention as noted by
clinical observations, informal
probes and parent feedback.
Inconsistency with
detection of speech
sound errors between
TH and in-person model.
Accuracy increased with
use of lapel microphones
creating increased
agreement between
conditions.
Child A and Child B
progressed in their
International Journal of Telerehabilitation • telerehab.pitt.edu
International Journal of Telerehabilitation
• Vol. 9 No. 1 Spring 2017
• (10.5195/ijt.2017.6219)
69
N=2. School-aged
(exact age unknown)
One SLP
treatment services
for 2 school-aged
children.
Equipment: custom TH
system with real-time VC,
document camera, room
cameras and television
monitors
Procedure: Structured
Photographic Articulation
Test conducted through TH
then in-person 3 days later.
Language Ax (TOLD-P:3)
conducted only in-person. Tx
conducted twice weekly for a
2-month period through TH.
Client satisfaction
documented via surveys
obtained post-treatment.
speech and language
goals over the 12
sessions.
Child A’s progress more
substantial than Child B.
Reliability and validity not
reported.
Parents reported
satisfaction with the
telehealth service and
the gains child made
during therapy.
Note. Ax = Assessment; CAS = Childhood Apraxia of Speech; F = Female; FCM = Functional Communication Measures; GAS
= Goal Attainment Scaling; GFTA-2 = Goldman-Fristoe Test of Articulation – 2nd edition, IEP = Individual Education Plan; M =
Male; Mx = Management; N = number; SDM = Service delivery model; SLP = Speech Language Pathology/ist; TH =
Telehealth; tx = treatment; VC = videoconferencing.
International Journal of Telerehabilitation • telerehab.pitt.edu
70
International Journal of Telerehabilitation
• Vol. 9, No. 1 Spring 2017
• (10.5195/ijt.2017.6219)
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.