While there is increasing interest in and implementation of telepractice for children who are deaf or hard of hearing across the country, there are few studies that systematically examine the differences in outcomes of children served using a telepractice model compared with children who have received services via a traditional in-person model. The multisite study reported here plays an important role in building on the knowledge gained related to the earlier study of the effectiveness of telepractice conducted by Blaiser et al. (2013). This study contributes to the research by (1) including more children who are DHH than have been involved in previously reported research studies; (2) using well-established norm-referenced, standardized tools of child language development; and (3) engaging diverse EI programs and providers from across the country.
The results pertaining to the impact of telepractice on service delivery itself are important, as demonstrated by the finding that the number of visits and minutes of intervention received were higher for the telepractice group. This can be viewed as a positive outcome of telepractice, while it also may be viewed as a product that confounds the child and family outcome data. To address this, the authors used the number of sessions received as a covariate to adjust for this factor and measure the impact of the service delivery mode alone. Future research that would systematically control the number of sessions received across groups would be useful. The service delivery data did not reflect dramatic reductions in cancelled visits per se, nor did telepractice appear to reduce negative impact on provider schedules as an often-theorized consequence of in-person visits. This may be due to a likely increased ease of rescheduling visits without necessarily counting the initial scheduled appointment as a cancellation. Because such outcomes have been reported in previous studies, these factors are important to be assessed in future research. Data from this study also reinforce the premise that telepractice can reduce drive time for providers, an aspect that impacts costs to programs. However, there is the need to consider time required for trouble-shooting and addressing technical issues when implementing telepractice. A report by the authors on a cost analysis of telepractice versus in-person visits is anticipated to be reported in the near future, and these nuanced issues will be addressed.
One particularly relevant outcome of this study pertains to the extent to which telepractice can promote the recommended practice of coaching families within the context of natural environments. In spite of this being widely accepted as best practice, past research has reported that the use of coaching has been a challenge for Part C providers during traditional home visits (Campbell & Sawyer, 2007; Colyvas, Sawyer, & Campbell, 2010; Peterson, Luze, Eshbaugh, Jeon, & Kantz, 2007). Unfortunately, many providers still demonstrate child-directed intervention while families observe rather than supporting the family as the child's natural teacher. Recent research found that the amount of time spent on parent–child interactions is associated with higher quality visits (Aikens et al., 2015) and that both the parenting environment and child language development are predicted by home visiting quality, particularly parent engagement (Roggman et al., 2016). The analysis of data obtained from the HOVRS-A+ in this study demonstrated that the families who received services via telepractice were more engaged in the intervention than the families in the in-person group, and providers were more responsive to the families when providing services via telepractice compared with those they served in the in-person group. Again, these findings reinforce those found in previous studies (Blaiser et al., 2013). When using telepractice, it is likely that the provider's reliance on communicating directly with the caregiver versus the child naturally fosters the increased use of coaching within the natural environment, thus increasing the use of this Part C-recommended principle.
The limitations of this study are important to keep in mind when interpreting the results and in guiding future research. First, this was an applied research design, which was vulnerable to the constraints of real-world EI programs. Random assignment was possible across some but not all of the sites, so every effort was made to match subjects on relevant characteristics and prescribed service. True random assignment would increase the scientific rigor. Second, although this study had a relatively large sample size in relation to the existing literature pertaining to telepractice with infants and toddlers, a larger sample size would increase statistical power and it would enhance the generalization of these results. Third, the child developmental measures were administered by the family's primary EI provider; ideally, objective testers blind to group assignment would have been used. Fourth, replication with a more culturally and linguistically diverse population of families is needed, given the homogeneity of the subjects in this study. Finally, additional observational data regarding the quality of the intervention sessions would be valuable beyond the single video recording collected in this study. Data pertaining to the technical aspects of the telepractice sessions, such as the number of video and/or audio interruptions, were not collected because of budgetary constraints. Further research that can address these limitations would be an important contribution to the efficacy of telepractice for this population.
This study verifies that telepractice can support the development of infants and toddlers who are deaf or hard of hearing, and it reinforces the use of telepractice to serve families of infants and toddlers with other special needs. However, these results must not be construed to mean that telepractice should take the place of in-person home visits. Rather, these findings reinforce the stance that telepractice is a valuable tool in the overall goal of EI, which is to deliver comprehensive, family-centered services. Ultimately, all aspects of intervention, including the format for service delivery, should be based on family needs, priorities, and cultural considerations. From a practical standpoint, telepractice can help reduce costs associated with provider travel and provider shortages, which are primary deterrents for programs serving this population. Therefore, these findings can inform policy makers, program directors, providers, and families of the value of incorporating telepractice into EI programs that serve not only those whose children are DHH but those serving the broader Part C population.
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