In November, Kristen Chmela—executive director of the Chmela Fluency Center in Long Grove, Ill.—chatted with participants from ASHA's online conference, Case Studies in Fluency Disorders. The Leader listened in.
Bahaa Sudqui Moh'd Abdeljawad: Hello, Ms. Chmela. I want to thank you for the new information you presented in this session. My questions are: What are the exact ages for clients involved in teletherapy? And are you able to observe all the environments and all behaviors, especially the secondary behaviors of the client?
Chmela: The child involved in this case study was a preschooler. I have also provided teletherapy for children through teens, as well as adults. Although we can't observe all environments-with any client-we do guide the parent or caregiver on what to observe and they provide us with daily information regarding the child's speech and associated characteristics.
Marney Vitthal: My question is not necessarily about your program specifically as much as it is about a theme I've noticed. In your program as well as two others, the speaker mentioned "sensitive children"-along with an increased possibility of stuttering, some difficulties, and modifications needed for therapy (for example, Lidcombe). Are you referring to Elaine Aron's theory of "highly sensitive children?"
Chmela: I am referring to research out of Vanderbilt University-by Conture and colleagues-as well as others in our field, such as Zebrowski, who have been looking at temperament in young children who stutter. Many children we work with are highly sensitive and we problem solve the treatment always to tailor to the needs of the child. I would also suggest reading Guitar and Kagan regarding sensitive temperament.
Beverly Edwards: I wondered if you make an attempt to meet with the client in person prior to beginning telepractice.
Chmela: Yes, I much prefer to do the initial assessment in person. If not, someone else does the assessment and then we collaborate to create the plan based on their findings… The hardest issue for me, as a specialist, is needing to be licensed across different states.
Alison Pollarine: What would be the difference in delivering therapy if the mother was not an SLP, and not so well trained to provide the directed therapy to her daughter?
Chmela: That would depend on the mother. Even though she was comfortable, I went ahead and approached the therapy as I always do, making no assumptions. It is very important that we teach parents directly how to model behaviors. Many of them may be confused about even how to model an easier approach to speaking.
Risa Radeke: In the Level 1 stage of treatment do you subscribe to a recommended schedule for follow-up, or is this individualized and varied to meet the needs and schedule of each family?
Chmela: It does depend on the family, but usually in Level 1 we like parents to follow up in 6-8 weeks. We may extend the follow-up period after that as well.
Gina Dwyer-Urban: Do you usually leave it up to the family to contact you for the follow-up, or do you contact the family after a specified amount of time to see how things are going?
Chmela: I usually mark in my calendar when we are going to follow up, and then we have a scheduled phone conference or meeting if necessary.
Cynthia White: I'm curious if it's more difficult to develop and keep a rapport with clients and their families through telepractice? How do you suggest working through this? And, in your experience, does follow-through and generalization tend to be more challenging?
Chmela: I have found that relationships through this mode take on their own "specialness." When I have seen children in person, they don't usually speak to me. I have not experienced more difficulty with follow-through. We have expectations for the client, and they must fulfill those in order for the treatment to be successful. If I am traveling to an area where I have seen a client, I will usually attempt to meet them in person.
Deborah Rodriguez: On average, how many sessions are spent on parent training?
Chmela: It depends on what level of treatment, but we may spend four to six sessions training a parent to model indirect approaches. When we are implementing the Lidcombe approach [a stuttering treatment technique in which the therapist teaches parents to provide the therapy], the parent is involved in every session. We train them to make ratings the first session, provide the positive contingencies the next two or so, add the negative contingencies, and then continue to problem-solve with them. We do spend time with many parents talking about sensitivities the child may have and problem-solving things with them such as making transitions easier-a time when stuttering increases frequently.
Carol Magee Venice: Kristin, how do you get referrals? Is telepractice available to everyone?
Chmela: I have been practicing for about 25 years, so I get referrals from my local area as well as from the Stuttering Foundation, and from colleagues across the world.
Judd Emery: Does the word "teletherapy" only refer to therapy in which technology is the primary way for connecting with a client, or could there be a benefit to using this technology also with clients who are near at hand?
Chmela: That is a good question. I do use this mode for some teens who don't live very far from me, but who are very busy with sports, and so forth, and sometimes can't make it to a person-to-person session.
Laura Irving: Have you ever had a situation where the family situation was just "not suitable" for teletherapy, even after your training?
Chmela: Yes I have. I have worked with families where I felt this type of service delivery was not the best, and I referred them on to someone else. It is very hard with fluency disorders, because often there are almost no other options.
Liz Ehrstein: What do you feel are the limitations of using telepractice with young children?
Chmela: Limitations include not being able to actually get down on the floor and play with them. You can comment as they are interacting with their parent or parents, but sometimes they also do not talk. In fact, we often have the parents "black out" the screen, so we can just watch them play but they can't see us. We work much more specifically with the parents of these children than with the actual child.
Debbie Lipton: How long have you been delivering therapy in this fashion via telepractice?
Chmela: For about four years now. It is not my main mode of service delivery, however. As a specialist, I think this type of delivery could assist other clinicians across the world with the difficult cases they have to deal with.
Debbie Lipton: How long did it take for you to become comfortable doing therapy this way?
Chmela: I am still working on being comfortable doing therapy this way. Sometimes I just wish I could go through the screen to the child, but the more experience I get the easier it is. It is very important that the other end of the therapy is set up properly: No background noise, a light on the child's and parents' faces, no dogs barking.
Gina Dwyer-Urban: Do you usually work to get both parents involved in the sessions?
Chmela: It depends. I usually ask for one and then the other. If I have two parents, with this delivery, it is a little tricky. We often switch back and forth. The parents must be involved.
Judd Emery: Have you often seen cases where the child seems unable to recognize a stutter, and yet still feel frustration or even struggle?
Chmela: I have seen frustration at not being able to think of a word, or formulate an idea. Sometimes children with apraxia demonstrate that as well, and yet they don't stutter.
Liz Ehrstein: We've reached the end of this chat session. Thank you so much.
For more information about ASHA's online conferences, visit www.asha.org/events.