Molly was born 10 weeks premature. As her parents prepared to take Molly home from the neonatal intensive care unit, they received news that she had failed her hearing screening. Follow-up tests indicated bilateral, profound sensorineural hearing loss, caused by the antibiotics used to keep her alive. She received bilateral cochlear implants when she was 13 months old.
A mom and her young daughter work with an ihear therapists using a variety of toys and incorporating language into her typical play routines.
Today, Molly lives on a farm in a rural community with her parents and older brother. Her grandparents run the neighboring farm and numerous aunts, uncles, and cousins live nearby. The family is close-knit, serving as one another's support system. To help develop Molly's spoken language, her mom contacts the state early intervention program's staff. They, in turn, refer her to a speech-language pathologist who visits her town once a month.
The SLP, however, has never provided intervention to a child with cochlear implants nor received any specialized training in using auditory skills to develop language. The SLP thinks Molly's family should work with a more experienced clinician, but no one in the area has the right training.
Molly's story is all too familiar. Even as advances in hearing technology help more children develop spoken language through listening, there is a shortage of SLPs trained to work with families to achieve these goals (ASHA, 2011). As a result, families living far from metropolitan areas might drive two or more hours every week to visit a professional, leaving children unable to learn in their natural environments.
Teacher of the Deaf, Barb Meyers, works with a child and her mother on responding to the onset of a sound by putting a peg into a peg board. This is a task that mom will work on throughout the week to help her daughter learn to respond to sounds.
The ihear Curriculum
Recognizing these limitations for families—as well as innovations in telepractice—St. Joseph Institute for the Deaf in St. Louis conducted a pilot study to deliver intervention via the Internet in 2008. The study examined a number of questions: Is service delivery over the Internet effective? How would St. Joseph staff know that the quality of the auditory signal—so critical for children developing auditory skills—was adequate? Could they build relationships with families and children online? How would they keep a 2-year-old's attention online, or monitor progress?
The result was the ihear™ Internet Therapy Program (ihear) and associated curriculum, which allows professionals trained in the development of listening and spoken language to deliver treatment to children with hearing loss, regardless of where the child lives, by coaching a parent or professional who is on-site with the child.
The ihear program includes computerized, interactive lesson plans that embed individual objectives within each session. The sessions are outcome-driven and include new strategies that the parent or professional (SLP, teacher of the deaf, or others) can use to improve a specific skill. The ihear program clinician—who may be an SLP or teacher of the deaf (TOD) who has specialized in developing spoken language through listening—coaches the parent or on-site professional to implement strategies, and empowers him or her to understand the needs of the child.
Each lesson focuses on the child's affinities and strengths to teach to individual objectives. Although digitized lesson plans are often used to target specific skills, the program allows therapists to, for example, access websites or utilize a white board to capture a child's interest. The length and frequency of sessions are based on the child's individual needs. Sessions occur as often as five times a week for 30 minutes for those children who are working on specific individualized education plan goals, and as little as every other week for 30 minutes for those children who are simply maintaining their language and auditory skills.
The ihear curriculum is based on three main components: coaching a clinician, parent, or caregiver in strategies to help children use their newly learned skills; maintaining the client's privacy under applicable federal laws; and gathering data to determine each lesson's efficacy.
Empowering by Coaching
Professionals at St. Joseph Institute for the Deaf use a coaching model in their family-centered early intervention. Therefore, the ihear program considered coaching as a means to serve the school-age population, either at home or in school. Coaching allows a child's local school professional—teacher of the deaf, SLP, or others—to help develop a child's auditory skills so the child can learn language and develop articulation.
Coaching builds a cooperative and collaborative relationship between the coach—in this case, the ihear clinician—and the on-site parent or professional through empowerment. The partnership between a school professional and ihear clinician makes them equals in the therapeutic process (Turnbull & Turnbull, 2001). Together they determine a specific, evidence-based coaching strategy to be practiced in each session. The ihear clinician demonstrates the coaching strategy and applies it during the intervention session, and the parent or professional then practices the strategy and receives feedback from the ihear clinician. For example, the child may delete the final /s/ from words, so the ihear clinician may suggest checking the child's auditory detection of the /s/ sound. Professionals depend on each other to help the child succeed.
This interdependence is critical for telepractice success, because the professional or parent working directly with the child keeps the ihear clinician apprised of quality indicators, and incorporates cultural and linguistic norms appropriate for the child's natural environment. For example, nuances of English can vary from region to region. One child recently talked about "silage," and the ihear clinician didn't know whether it was a noun or a verb, or what it meant. The child's mother explained that silage is the food their farm animals eat. The parent's support prevented a communication breakdown between the clinician and the child.
Clinicians providing coaching via telepractice—like all clinicians providing services—must adhere to the ASHA Code of Ethics and federal and state laws if applicable (ASHA, 2005), including the Health Insurance Portability and Accountability Act (HIPAA) and Family Educational Rights and Privacy Act (FERPA). For more information about how HIPAA relates to the use of telepractice, visit ASHA's frequently asked questions.
For Molly's family, and all the families ihear works with, we wanted to ensure their internet sessions and personal information were secure. The ihear program uses proprietary, noncommercial software that is certified HIPAA- and FERPA-compliant. Other considerations that maintain privacy are the security of treatment rooms during sessions. Identify all people at both sites prior to each session, or whenever someone new enters the session. When a child enrolls in the program, the family or school district works with an ihear technical specialist to ensure that the on-site computer and Internet connection function properly. The ihear technician also installs necessary software on the client's computer.
Consistent with ASHA's position on telepractice (ASHA, 2005), the ihear program ensures that services provided to the children are of the same quality as those occurring within the classrooms at St. Joseph Institute for the Deaf.
To measure the quality of services, ihear used the Internet Therapy Outcome Tracking System (iTOTS™) to monitor and assess intervention efficacy. iTOTS monitors all aspects of the ihear program, with two goals: to aggregate data about the program's overall efficacy (including Internet service quality, ihear clinician quality via Internet, and digital lesson plan effectiveness) and to collect data assessing children's progress toward their objectives. In many instances these goals overlap, but analysis occurs individually. Data analysis demonstrates the child's ability to increase a skill, the lesson's ability to engage the child, and the parent or professional's ability to use the strategy in which they've been coached.
At 10 months old, before she received her implants, Molly began ihear telepractice services twice a week for 30 minutes per session. Molly used a few single-word utterances and approximately 50 "baby signs." The ihear clinician coached Molly's parents in strategies to develop auditory skills and increase her expressive language. For example, when the phone rang during an ihear session, the ihear clinician taught mom to alert Molly to the sound by pointing at her ear and saying, "Molly, I hear something...do you?" Reinforcing teachable moments in the natural environment makes listening a part of everyday routines. The ihear clinician embedded a strategy, and modeled a technique for skill development.
When she began the program, Molly's standardized assessment score for spoken language was 68, well below the average range of 85-115. Six months later—with her parents and grandparents incorporating the coaching strategies into Molly's daily activities and routines—her score increased to 82. She talked in three- to four-word sentences and her expressive vocabulary increased almost daily. Molly's language growth continued as her family learned more strategies over the next two years.
In addition to the ability to communicate with their daughter, Molly's family also gained less tangible—but equally important—benefits. They are learning how to meet her needs and are comfortable helping teach her to listen and talk. And they are able to stay in their close-knit community with appropriate support systems, despite their remote location.
According to Molly's mom, "ihear benefited our family by teaching us how to communicate with our daughter. We are learning so much from our sessions about meeting her needs...knowing what she wants and giving her language to express those wants. Now, we're more comfortable with the process of teaching her how to listen and talk. We no longer feel 'out there,' on our own without any support."