Graduation Year

2021

Document Type

Dissertation

Degree

Ph.D.

Degree Name

Doctor of Philosophy (Ph.D.)

Degree Granting Department

Communication Sciences and Disorders

Major Professor

Howard Goldstein, Ph.D.

Committee Member

R. Michael Barker, Ph.D.

Committee Member

Michelle Bourgeois, Ph.D., CCC-SLP

Committee Member

Robert Dedrick, Ph.D.

Committee Member

Trina Spencer, Ph.D., BCBA-D

Keywords

coronavirus pandemic, speech sound assessments, Goldman Fristoe Test of Articulation -3rd edition, telehealth survey

Abstract

The COVID-19 pandemic potentially changed the landscape of how speech-language pathologists provide services. Prior to March 2020, pediatric speech-language therapy provided via telehealth was limited; however, the COVID-19 pandemic caused a worldwide conversion from in-person care to a remote service delivery model. This conversion brought to the fore possible benefits and utility of telehealth use. Yet, clinicians potentially experienced barriers to its use, including the lack of validity and reliability evidence for remote administration of several pediatric assessments. For the viability of remotely delivered speech-language services to continue and evolve in a post-pandemic world, further research is needed to identify changes to telehealth barriers and benefits. This manuscript includes investigations into how telehealth delivery of pediatric speech-language pathology services changed as a result of the COVID-19 pandemic, and also examined the extent to which clinicians’ reservations about the reliability and validity of telehealth speech sound assessments were justified.

Study 1 sought to capture changes in speech-language pathology clinicians’ telehealth experiences before and during the COVID-19 pandemic and predictions about post-pandemic telehealth services. The Telehealth Services: Pediatric Provider Survey (Part 1) was created to gather self-reported responses from speech-language clinicians in a variety of employment settings who were serving primarily pediatric (i.e., children from birth through age 21) clients. Survey results documented how pediatric speech-language clinicians’ (n=293) use of telehealth dramatically increased from before March 2020 to October 2020. This shift from in-person care to synchronous videoconferencing effectively created a new generation of telepractitioners. Even though most clinicians initially used telehealth due to employer mandates to lower infection risk for both client and clinician, over time pediatric speech-language pathology clinicians increased their telehealth proficiency and recognized the benefits of telehealth. This new generation’s adoption of telehealth and the rapid improvement in proficiency was a testament to the resiliency of providers and potentially had long-term effects on the future of telehealth use.

Study 2 examined the resulting evolution in the technology, connectivity, and the extent of implementation of evaluation and treatment services before and during the COVID-19 pandemic and predictions about post-pandemic telehealth services. The Telehealth Services: Pediatric Provider Survey (Part 2) was created to identify telehealth barriers that were eliminated and those that persisted during the pandemic. Additionally, the survey sampled pediatric speech-language clinicians’ perceptions about advantages and disadvantages of remote delivery of evaluation and treatment services. Elimination of regulatory and insurance hurdles allowed children from varying socioeconomic backgrounds living in rural, suburban, and urban areas access to telehealth. Telehealth technology shifted from computers with external hardware and specialized software to commercially available equipment, such as handheld portable devices with built-in audio-visual components and publicly available videoconferencing platforms. Connectivity of these devices continued to be problematic, however, and lack of technology prevented some children from accessing care. Judgments about the appropriateness and effectiveness of evaluations and treatments varied based on the age and communication disorder of a child. Although some participants expressed uncertainty about the effectiveness of telehealth compared to in-person care, telehealth was widely recognized as a viable delivery method. Clinicians anticipate that new research and innovations resulting from the surge in telehealth use have the potential to continue improving telehealth service delivery, bolstering the viability of telehealth long after the COVID-19 pandemic is gone.

Study 3 investigated the reliability and validity of a speech sound assessment administered in real-world scenarios. Thirty-nine three- to eight-year-olds were administered the Goldman Fristoe Test of Articulation-3rd Edition (GFTA3). Using a counterbalanced administration, licensed speech-language pathologists (SLPs) concurrently scored the children’s responses in person, and in two telehealth conditions, typical and enhanced. The results were compared mean composite scores and interrater reliability and descriptive statistics summarized scoring disruptions and findings on the SLP post-assessment survey. Results revealed that all scoring conditions were highly correlated, with mean differences revealing no significant systematic difference of one condition over- or under-estimating another. Final sounds in words (e.g., /l/), sounds that were difficult to see (/g/) and some cognate pairs (e.g., t/d) most often attenuated reliability, which still averaged 85-87% agreement between conditions. Reported child behavior and technology disruptions did not affect SLPs’ ability to score responses, mainly because of the GFTA3’s administration procedures that allow target items to be prompted or repeated. Therefore, this study supports the provision of a pediatric speech sound assessment using consumer-grade equipment, as in person, typical telehealth, and enhanced telehealth scoring conditions produced nearly identical scoring results. However, SLP participants’ post-assessment survey results revealed skeptical attitudes toward remote delivery of standardized tests, an ongoing barrier to widespread telehealth use.

Pediatric speech-language pathology clinicians’ experiences during the COVID-19 pandemic were unprecedented. It forced an entire generation of clinicians and their clients to quickly adapt and evolve into a therapy world that was contingent on technology. Yet, the necessity of telehealth revealed to clinicians its many benefits. Sadly, it also brought to their attention telehealth’s ongoing barriers, such as the significant deficiencies in research that support the use of telehealth. These studies represent the beginning of a new age of telehealth research.

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