Language Intervention via Text-Based Tele-AAC: A Case Study Comparing On-site and Telepractice Services

Abstract

There is a shortage of qualified speech and language pathologists (SLPs) to not only meet the needs of students with a variety of communicative disabilities, but also the needs of those students with severe impairments who use augmentative and alternative communication (AAC). Special education administrators need to consider additional methods of service delivery, such as telepractice. However, there is limited evidence regarding the efficacy of services delivered to students using AAC via telepractice as opposed to face-to-face services. This study examines the effectiveness of services provided using both methodologies, and aims to provide some validation of telepractice as an alternative treatment method. Using a single-subject design to compare performance outcomes, a 7 year-old male participant, who used a Vantage Plus™ device with an 84-sequenced overlay, was studied over an eight-week period, with four weeks of on-site therapy immediately followed by four weeks of telepractice therapy. Student progress was measured by comparing outcomes in both conditions to baseline data with respect to short-term goals focused on grammatical morphemes. The results indicate that the performance outcomes were comparable in both conditions. The authors discuss the implications of using telepractice to deliver direct intervention and future applications of telepractice as a service delivery model for individuals using AAC.

Full text

Language Intervention via Text-Based Tele-AAC: A Case
Study Comparing On-site and Telepractice Services
Nerissa Hall
Commūnicāre, LLC/C.A.R.E. Consortium
Westfield, MA
Michelle Boisvert
WorldTide, Inc./C.A.R.E. Consortium
Williamsburg, MA
Hillary Jellison
Commūnicāre, LLC/C.A.R.E. Consortium
Westfield, MA
Mary Andrianopoulos
Department of Communication Disorders, University of Massachusetts
Amherst, MA
Financial Disclosure: Nerissa Hall is a Speech-Language Pathologist at Commūnicāre, LLC/C.A.R.E.
Consortium. Michelle Boisvert is a CCC speech-language pathologist at WorldTide, Inc./
C.A.R.E. Consortium. Hillary Jellison is a Speech-Language Pathologist at Commūnicāre,
LLC/C.A.R.E. Consortium. Mary Andrianopoulos is an Associate Professor in the Department of
Communication Disorders at the University of Massachusetts.
Nonfinancial Disclosure: Nerissa Hall has previously published in the subject area. Michelle
Boisvert has previously published in the subject area. Hillary Jellison has previously published in
the subject area. Mary Andrianpoulos has previously published in the subject area.
Abstract
There is a shortage of qualified speech and language pathologists (SLPs) to not only meet the
needs of students with a variety of communicative disabilities, but also the needs of those
students with severe impairments who use augmentative and alternative communication
(AAC). Special education administrators need to consider additional methods of service
delivery, such as telepractice. However, there is limited evidence regarding the efficacy of
services delivered to students using AAC via telepractice as opposed to face-to-face services.
This study examines the effectiveness of services provided using both methodologies, and
aims to provide some validation of telepractice as an alternative treatment method. Using
a single-subject design to compare performance outcomes, a 7 year-old male participant, who
used a Vantage Plus™device with an 84-sequenced overlay, was studied over an eight-week
period, with four weeks of on-site therapy immediately followed by four weeks of telepractice
therapy. Student progress was measured by comparing outcomes in both conditions to
baseline data with respect to short-term goals focused on grammatical morphemes. The
results indicate that the performance outcomes were comparable in both conditions. The
authors discuss the implications of using telepractice to deliver direct intervention and future
applications of telepractice as a service delivery model for individuals using AAC.
Augmentative and alternative communication (AAC), a subset of assistive technology (AT),
is an evolving and expanding area of need within rehabilitative services. In school-based settings,
the use of AAC devices to enhance individuals’communication accounts for approximately
3–5% of all K-12 students (Matas, Mathy-Laikko, Beukelman, & Legresley, 1985) and 12% of all
preschoolers (Binger & Light, 2006). Data analyzed from the US National Survey of Children
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Hall, N., Boisvert, M., Jellison, H., & Andrianopoulos, M. (2014). Language Intervention via Text-Based Tele-AAC:
A Case Study Comparing On-site and Telepractice Services. American Speech Language Hearing Association.
ASHA. SIG 18 Perspectives. doi: 10.1044/teles4.2.61

with Special Health Care Needs (CSHCN) revealed that 12% of special needs children require
communication, hearing or mobility devices such as those typically provided by rehabilitation
professionals and as many as 14% of these children are reported to have unmet needs (Benedict &
Baumgardner, 2009, p. 586).
The Individuals with Disabilities Education Act (IDEA; 2004) and the No Child Left Behind
Act (NCLB; 2001) mandate that students with communication disabilities who use AT (including
AAC), should receive evidence-based services from highly-qualified professionals. However, due
to a shortage of rehabilitation professionals qualified to provide such services, many schools are
unable to meet the needs of their students (American Association of Employment in Education,
2008; American Speech Language Hearing Association, 2014). As a result, many eligible students
with complex communication needs do not receive services, or receive services from unqualified
personnel (Boisvert, Lang, Andrianopoulos, Boscardin, 2010; Rule, Salzbert, Higbee, Menlove, &
Smith, 2006). Additional data analysis from the National Survey of Children with Special Health
Care Needs revealed that the “prevalence of unmet need for assistive devices among children
with a reported need [was] ... 24.7% for communication aids”(Dusing, Skinner, & Mayer, 2004,
p. 450). This discrepancy between documented need and access to medically appropriate services
adversely impacts students’advancement of critical communication skills, academic achievement,
and development of essential social relationships.
The demand for evidence-based services conducted by highly-qualified licensed speech
language pathologists and/or assistants has lead researchers to consider technology, such as
telepractice, as a means to provide services to students impacted by this personnel shortage.
According to ASHA (n.d.), telepractice can be used to provide professional services at a distance for
assessment, intervention and/or consultation. Telepractice involves the application of communication
technologies (e.g., videoconferencing software and the Internet), which enables specialists to deliver
real-time, interactive services over a geographical distance (Dudding, 2009). The implementation
of telepractice is a promising method to overcome the impact of the personnel shortage as it
enables experts to provide services to students in both their school and home environments.
Case Study
In an effort to directly address the documented need for AT and AAC intervention and
shortage of speech language pathologists (SLPs), this case study was designed to explore the use of
telepractice for an individual using AAC.
Purpose
This study aimed to: (a) determine the feasibility of providing direct services via telepractice
to an individual using AAC, and (b) compare the individual’s progress in meeting speech and
language goals and objectives when services were provided on-site versus via telepractice.
Experimental Design
For this feasibility study, a single case, ABC design was used to evaluate the effectiveness
of language intervention for a non-verbal device user (outputted using AAC) to generate three
target grammatical morphemes. Services were delivered for an equal number of sessions and
weeks both onsite and via telepractice settings. Stable baseline probes were established over the
course of four weeks per service delivery modality. Each intervention condition was four sessions
in length, for a total of eight intervention sessions.
Dependent Variables
The dependent variables consisted of three (3) target morphemes for intervention services
with respect to the appropriate use of: (a) progressive verb form –ing; (b) past tense verb form –ed;
and (c) the plural –sat the four-word sentence level. Probe data were obtained at the beginning
of the onsite and telepractice intervention sessions with respect to the frequency of generating
each morpheme and the frequency of each morpheme’s use. No prompting or cueing was provided
when probe data were measured.
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Independent Variables
The independent variables in this investigation were the method of service delivery,
specifically: (a) in-person onsite intervention services, and (b) intervention provided via telepractice.
Participant
A 7 year-old male diagnosed with schizencephaly, a rare developmental birth defect
characterized by abnormal clefts in the cerebral hemispheres of the brain, participated in this
study. Children diagnosed with this syndrome commonly exhibit delays in development, the
acquisition of speech and language, and problems with brain-spinal cord communication
(National Institute Neurological Disorders and Stroke, 2012). The participant presented with
significant expressive language deficits inherent to the syndrome and was prescribed a Vantage
Plus™AAC device. The participant presented with a left hemiparesis, but accessed his device
via direct selection using his index finger of his right hand. At the time of this investigation, the
participant was using an 84-sequenced overlay to communicate and received services under an
Individualized Education Program (IEP) for speech and language. To be included in this feasibility
study, the following inclusion criteria were met: (a) a formal diagnosis of an expressive language
disorder assessed and confirmed by a certified and licensed SLP; (b) a prescription of an AAC
device to facilitate expressive language output; (c) demonstrated use of the AAC device for functional
verbal communication; (d) demonstrated ability to follow directions; (e) demonstrated attentiveness
for more than 10 minutes; (f) normal hearing and visual ability; and (g) minimal manual dexterity to
operate the keyboard and engage in button selections on the AAC device. The participant selected
for study met all inclusionary criteria.
The participant and his family were motivated to partake in this study and completed the
informed consent form required for participation. This study was approved by the University of
Massachusetts-Amherst’s Internal Review Board (IRB) and was conducted by the first author as a
third year doctoral student at the University of Massachusetts-Amherst in the Department of
Communication Disorders. At the time of this study, the first and second authors were funded
under a grant received by the fourth author from the U.S. Department of Education Office of
Special Education Programs (H325D080042).
Setting and Materials
One-on-one onsite and telepractice intervention services were provided to the participant
in his home in a consistent location. The participant had access to a table with the required
intervention equipment while seated in his wheelchair. As depicted in Figures 1 and 2, during all
sessions the participant was seated facing Computer 1. The purpose of Computer 1 was to display
activities and material, which remained constant for both onsite and telepractice conditions.
Computer 1 was oriented slightly to the participant’s left. The participant used his right hand to
access his device. Therefore, his Vantage Plus™AAC device was placed to his right in an optimal
position for efficient device access. For all onsite and telepractice sessions, Computer 1 was used
consistently to display materials and activities for therapy.
Figure 1. Onsite Service Delivery
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During onsite sessions, the clinician was seated to the participant’s right, and a parent
was seated to the participant’s left (see Figure 1). The positioning of equipment and the parent’s
seating was maintained when services were provided via telepractice. However, during the
telepractice sessions, the second computer (Computer 2) was placed to the left of the participant in
the location where the parent was positioned (with his device remaining on the right) as the second
computer needed to be plugged into an electrical outlet on the left (see Figure 2). The screen of
Computer 2 was used for videoconferencing and allowed for the clinician to be recorded during the
telepractice intervention sessions.
Probe and intervention materials were developed in MicrosoftWOffice Word 2007 and
Boardmaker Studio™. The same intervention materials were used onsite and in-person, as well as
during the offsite services delivered via telepractice phase.
Equipment
During the onsite phase, the clinician used a Hewlett-Packard (HP) TouchSmart tx2
(without implementing the touchscreen feature), Boardmaker Studio™, and MicrosoftWOffice
Word software programs. The HP ran a Microsoft Vista™operating system and had a 2.20 GHz
processor with 4GB memory. Similarly, for the telepractice services, the clinician used the same
HP TouchSmart tx2 with the above-mentioned software programs. All electronic material was
screen-shared from the clinician’s computer to the participant’s laptop computer. In addition, the
clinician utilized a second eMachine desktop computer with a Microsoft LifeCam external webcam
mounted on top of the monitor to engage in real-time videoconferencing through Skype™. The
eMachine ran the Microsoft Windows 7 operating system and had a 3.1GHz processor and
3GB memory. The Microsoft webcam had an auto-focus lens and captured 720p HD video with
30 frames per second. The clinician’s eMachine desktop computer used for videoconferencing
(Computer 2) and was connected to high-speed Internet through an Ethernet cable. The HP
TouchSmart tx2, as previously mentioned was used to present activities and material to the
participant through screen sharing, and was connected wirelessly to high speed Internet.
At the participant’s home location, the parents’desktop Dell Pavilion dv6 computer (with
a Windows 7 operating system, a 2.3GHz processor, 8GB memory and built-in TrueVision HD
Webcam with an integrated digital microphone) was used solely for videoconferencing purposes.
The participant also used a Dell Inspiron 1505 laptop (with Windows XP™, IntelWCore™2Duo
processor, and 2GB of memory) to view materials through screen-sharing software and interact
with the clinician. The computers in the participant’s home used a wireless Internet connection for
both videoconferencing and screen sharing.
For the onsite sessions, the participant’s AAC device was connected to the clinician’s
computer using a standard USB printer cable. During the second phase, services switched to
telepractice sessions. The participant’s device remained connected to the Dell laptop computer
Figure 2. Telepractice Service Delivery
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using the same standard USB printer cable. The output feature of the participant’s AAC device
was turned on to ensure that the messages generated on his device were presented in the body of a
word-processing document (i.e., in the message window on Boardmaker Studio™or directly into
the body of the document in MicrosoftWOffice Word) and were subsequently screen-shared with
the clinician. Using screen sharing capabilities, all messages inputted through the device were
immediately visible to the clinician irrespective of the clinician’s physical location.
Videoconferencing software was used during the telepractice session to simulate the face-
to-face interactive nature of direct services. Skype™, a free desktop videoconferencing application,
was used for the video and audio communication. Skype™software uses 256-bit Advanced
Encryption Standard (AES) encryption to encrypt communication between users, is compatible
with Macintosh and Windows operating systems, and has voice, video call, and instant messaging
functionality (Skype Technologies S. A., 2011). AdobeWConnectNow, was used for screen-sharing
purposes during the telepractice phase of the investigation. Using this software, intervention
materials were shared between the clinician and participant (located at the two different sites).
AdobeWConnectNow is a web conferencing system used for online meetings, eLearning, and
webinars. The system is flash-based and offers free online meetings for up to two people per
meeting. AdobeWConnectNow implements Secure Sockets Layer (SSL) technology for both server
authentication and data encryption.
Procedures
Baseline Sessions
Baseline data were obtained outside of the intervention environment four weeks prior to
the onset of the study. During this time, the participant was not introduced to telepractice
technology or the associated material. The objectives were derived from the participant’s IEP
speech and language goals and performance outcomes during the baseline observations. The
participant produced only limited spontaneous productions on his device of the grammatical
morpheme targets with respect to the following morphemes: progressive verb form –ing; the past
verb form –ed; and the plural –s. The participant was presented with prompt questions to elicit
and assess the use of target objectives in an independent setting. The data for the baseline prompts
were collected in the absence of any cueing or support from the clinician. However, informal
observations during the baseline phase revealed that the participant relied on moderate-to-
maximum support from paraprofessionals, clinicians, teachers, and parents in the form of visual,
verbal, and tactile prompting to generate any grammatical morphemes using his speech-
generating device via icon selection rather than spelling.
Intervention Sessions
Intervention sessions were 60 minutes in length and consisted of two parts: (1) a pre-
intervention grammatical morpheme probe; and (2) grammatical morpheme intervention. The
pre-intervention probe task consisted of presenting two pictures representing plurality and
four pictures representing verbs. Probe questions were randomly selected and varied throughout
the course of the study to account for a learning effect. The participant’s responses to probe
questions were produced by selecting icons on his speech-generating device (rather than spelling
on the keyboard), which was connected to the computer. A text-based response was generated for
each probe. As previously stated, during the probe tasks the participant did not receive any prompting
or cueing from the clinician or his parents. Each probe task was approximately 10–15 minutes
in duration. Following the probe phase, the target grammatical morpheme intervention activities
consisted of models, recasts, and contrastive statements provided by the clinician to support
the participant’s use of appropriate grammatical morphemes within the context of books and
self-generated stories. These activities lasted approximately 40–45 minutes in duration.
During the four-week onsite implementation condition, the clinician traveled 30 minutes
each way to the participant’s home for four, 60-minute intervention sessions. Prior to the start of
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each session, the participant’s device was connected via a USB cable to Computer 1 to ensure
that all phrase and sentence constructions generated through selection of icon sequences were
represented on the monitor. The clinician provided services at the participant’s home and all
probes and treatment materials were presented using the computer at the participant’s home. The
participant responded by using his device, which was connected to the computer. For example,
when presented with a probe picture and subsequent question, the participant responded by
using his device to select icons that displayed a text answer in the text field on the computer. This
enabled the participant, parent, and the clinician to view a text-based representation of the device
output on the computer monitor.
For the telepractice setting, the participant’s parents turned on the workstation and
connected to the clinician via Skype™and AdobeWConnectNow for the four, 60-minute
intervention sessions. Similar to the onsite interventions, the participant’s device was connected to
the computer and all probe and therapy material was presented on the monitor. Through the
screen-sharing application on AdobeWConnectNow, the participant was able to view all stimuli
(i.e., probe and intervention activities) presented by the clinician and respond to questions using
his device. The clinician transferred control of the mouse to the participant if the therapy material
presented during the session on the shared screen required a response. The clinician and
participant interacted via videoconferencing. Responses to all stimuli occurred through inputting
messages into text-based programs (through selection of icon sequences for the participant and
through typing for the clinician) onto the computer, consistent with the onsite interactions.
Data Analysis
Statistical analyses and comparisons of baseline data and the two intervention stages were
performed using visual inspection as well as non-parametric analysis using an Improved Rate
Difference (IRD) and the Tau-U analysis. The IRD calculation is supported in the literature as an
appropriate and effective statistic for use in medical research (Parker, Vannest, & Brown, 2009) and
it is applied to single case research to express the difference in performance outcomes between
baseline and the subsequent intervention measurements. The IRD is determined by comparing the
improvement rate between two phases (i.e., measuring non-overlapping data points) and is better
correlated than frequently utilized effect/size measurements with percent of non-overlapping data
(Parker et al., 2009).
The Tau-U is a nonparametric method for measuring the non-overlapping data between
two phases. The Tau-U combines non-overlap between phases with trends from within each
intervention phase. It is a “distribution free”technique that results in a z-score and level of
significance value (Parker, Vannest, Davis, & Sauber, 2011). This analysis enabled the authors
to compare and determine if there was a correlational difference in the participant’s outcomes
based on probe and intervention data when services were delivered in an onsite versus telepractice
setting. For all statistical analyses, the level for non-directional, statistical significance was set
at .05.
Probe data were collected at baseline and throughout treatment phases for both onsite
and telepractice intervention conditions. The baseline probe data were compared to the onsite
treatment probe data collected from the first condition using the IRD calculation. The Tau-U
calculation was used to compare the baseline probe data to the probe data from the two treatment
conditions. This method was also implemented to compare probe data collected during the onsite
condition to the probe data collected during the telepractice condition. Similarly, the number of
independent responses observed during the onsite condition was compared to the number of
independent responses observed during the telepractice condition.
Results
Table 1 illustrates that the participant’s documented baseline probe outcomes as compared
to the onsite probe outcomes yielded an IRD of 1.00, which suggests that all treatment probe data
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exceeded baseline probe data. These results support that the intervention had a “large to very
large”(Parker et al., 2011, p. 147) effect. The Tau-U analysis suggests that a statistically significant
correlation between baseline probe data and onsite probe data exists (p < .05).
Moreover, a statistically significant correlation was evident when comparing baseline probe
data to telepractice probe data (p < .05). A comparison of the probe data from the two treatment
conditions resulted in a non-statistically significant correction (p = 0.25), which supports that
intervention outcomes did not vary when services were delivered via onsite versus telepractice. The
Tau-U method was used to compare the number of independent responses the participant made
during intervention when receiving onsite services as compared to telepractice services. This
analysis resulted in a statistically significant correlation between the numbers of independent
responses made during the onsite condition as compared to the telepractice condition (p < .05);
however, the authors believe that this outcome may be more a reflection of a learned skill rather
than a statistical difference due to service delivery method.
Figure 3 illustrates that the participant achieved and maintained target goals across
intervention settings regardless of service delivery method. Visual inspection of pre-intervention
probe data (i.e., probe data obtained at the start of each session) revealed an increase in the
participant’s use of icon selections to generate the target morphemes, progressive verb form –ing,
the past tense verb form –ed, and the plural –sgrammatical during the intervention phases. The
participant’s accuracy on pre-intervention probe tasks steadily increased from 33% to 83.3% to
100% during subsequent sessions.
As illustrated in Figure 4, data obtained from the intervention seasons during structured
and unstructured intervention tasks revealed that the participant’s use of the target grammatical
morphemes increased, as did his level of independence producing the targets as evidenced by the
contrasting prompted versus independent data. Visual inspection of prompted versus independent
productions of the grammatical targets illustrated that independent responses increased, while
prompted responses decreased as the intervention progressed.
Table 1. Statistical Analysis for Participant.
IRD Tau-U
Baseline Probe vs. On-site Probe 1.00 p < .05
Baseline Probe vs. Telepractice Probe p < .05
On-site Probe vs. Telepractice Probe p = .25
On-site Independent Responses vs. Telepractice Independent Responses p < .05
Figure 3. Percentage Probe Accuracy
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Treatment Fidelity
To ensure experimental control of the independent variable, the onsite and offsite conditions
were controlled for the number of session per service condition (four onsite vs. four telepractice
sessions) and length per session regardless of method of service delivery (60 minute sessions). The
treating clinician, material used, and location of the participant during services remained constant
between the two conditions.
Treatment fidelity was estimated by comparing the collection of the probe data in which
the participant engaged during the intervention activities without clinician cueing and prompting.
The participant’s responses to activities presented during the intervention phases were also
text-based and to ensure the reliability of the data collected, judgments were made to determine
whether a response was either independent or required clinician prompting. A second trained
coder viewed 20% of the total data (a standard set by Fey, Cleave, Long, & Hughes, 1993) and
judged whether the participant’s responses were independent or prompted.
Inter-rater reliability was determined using point-by-point inter-observer agreement. This
was calculated by dividing the number of agreements by the total number of agreements and
disagreements and multiplying by 100. The inter-observer agreement scores for the prompting
provided were 98%, suggesting a high level of agreement.
Discussion
Research investigating the use of tele-AAC, telepractice for direct services with students
who use AAC devices, is extremely limited. The lack of research may be due to the more recent
emergence of telepractice as a potentially effective therapeutic method, and/or the perceived
limitations of this method of intervention with respect to individuals with severe complex
communication needs.
This present study examined what differences, if any, were evident in a participant’sprogress
and treatment outcomes on three target grammatical skills when intervention was delivered in an
onsite setting as compared to a telepractice setting. Results of the probe data revealed a significant
increase in target grammatical productions when the intervention sessions were compared to the
baseline data. The findings also suggest that there was not a significant correlated difference between
the probe data collected during the onsite intervention condition as compared to the telepractice
intervention condition. A comparison of the number of independent responses found that there was
a statistical correlated difference between the two treatment conditions in that the participant
demonstrated an increase in the number of independent responses during the telepractice condition.
The visual inspection of intervention data supports this finding and suggests that the participant’s
independent productions of grammatical targets increased, while prompted productions decreased.
Figure 4. Percentage of Independent vs. Prompted Responses Within Activities
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However, as previously mentioned, these results must be interpreted with caution as the authors
believe that the level of independence demonstrated during the second treatment condition may
reflect the participant’s learning throughout the investigation period. It is plausible that this
observation would have been noted regardless of the order of intervention settings.
This feasibility study was conducted with one participant; however, the clinical implications
of these preliminary results are promising. This study demonstrates that the implementation of an
evidence-based protocol during an AAC intervention program onsite as compared to a telepractice
delivery method were equivalent. This finding was evidenced by the non-significant correlated
relationship between probe data during the onsite versus telepractice sessions.
The authors speculate that the use of text-based intervention materials supported the
transition between onsite and offsite services. In addition, during the telepractice setting, the
representation of the participant’s device output into a shared document compensated for
the clinician’s inability to directly zoom in and view the participant’s device via videoconferencing
software. Thus, the clinician was able to provide individually-tailored feedback based on the
shared document irrespective of the physical location.
The results of this study have several implications for clinical practice and intervention
for individuals with AAC. First, this study found that grammatical morpheme intervention is
successful when implemented through onsite versus telepractice service delivery. Second, this
study demonstrated that telepractice can be successful with nonverbal individuals who have
complex and severe communication needs and physical disabilities. As such, professionals
can now feel more confident when considering the use of telepractice as a method to provide
intervention to individuals irrespective of their geographical location. Despite the shortage of well
experienced SLPs, especially with expertise in AAC, service delivery via telepractice has the
potential to significantly improve access to intervention services for students with special needs,
including those who require assistive technologies such as AAC systems.
Limitations
This feasibility study employed a single-subject research design with only one participant
and one treating clinician. The ability to generalize the results to other AAC device users is limited.
In addition, as the goal of this feasibility study was to determine whether or not telepractice is a
viable mode of service delivery for individuals utilizing assistive technologies, this investigation did
not include a reversal phase to further confirm the participant’s progress. Lastly, this investigation
used text-based responses and intervention materials to compensate for difficulties viewing the
device screen when using internal webcams and as a result, cannot generalize to individuals with
literacy-based challenges.
Directions for Future Research
This study is one investigation that was data driven and controlled for various factors, thus
it provides some evidence regarding the success of providing intervention services via telepractice
to a non-verbal AAC device user. Telepractice is one means to address the critical shortage of
speech and language specialists. It is suggested that future research explore the use of tele-AAC
with a greater number of AAC device users using a variety of AAC systems and data driven, or
evidence-based interventions. It is suggested that clinical researchers also examine the use of
telepractice with individuals with other communicative disabilities, such as those with significant
cognitive and physical disabilities, to determine what additional supports, hardware, software,
and techniques can be implemented within the therapeutic context. Additional research is needed
to explore these issues and to further investigate the components required to deliver services in a
systematic framework that will support the implementation, sustainability, fidelity, and validity
of telepractice services.
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