Systematic Review

Literacy Assessment Via Telepractice Is Comparable to Face-to-Face Assessment in Children with Reading Difficulties Living in Rural Australia

M. Antoinette Hodge, DPsych,1 Rebecca Sutherland, MHSc,1

Kelly Jeng, MClinNeuropsych,1 Gillian Bale, BA, MInclEd,2

Paige Batta, GradDipPsych,2 Aine Cambridge, BEd,2

Jeanette Detheridge, MA,2 Suzi Drevensek, BAppSc,1

Lynda Edwards, MEd,2 Margaret Everett, DipTeach,2

Chelvi Ganesalingam, PhD,1 Philippa Geier, BEd,2

Carol Kass, BEd,2 Susannah Mathieson, MEd,2

Michael McCabe, MCounsPsych,2 Kay Micallef, BEd,2

Kirsty Molomby, BA (Hons),2 Silvia Pfeiffer, PhD,3

Sylvia Pope, BEd,2 Francine Tait, BEd,2 Marcia Williamsz, MA,1

Lynne Young-Dwarte, BEd,2 and Natalie Silove, MBBS1,4

1Child Development Unit, The Children’s Hospital at Westmead, Westmead, Australia. 2NSW Centre for Effective Reading, New South Wales Department of Education, Wagga Wagga, Australia.

3CSIRO Data 61, Eveleigh, Australia. 4Faculty of Medicine, The University of Sydney, Sydney, Australia.

Abstract Background/Introduction: Literacy difficulties have signifi-

cant long-term impacts on individuals, and therefore early

identification and intervention are critical. Access to experi-

enced professionals who conduct standardized literacy as-

sessments with children is limited in rural and remote areas.

The emerging literature supports the feasibility of using tel-

epractice to overcome barriers to accessing specialist literacy

assessment. The current study sought to determine the feasibility

and reliability of telepractice assessments, using consumer-

grade technology, in children with reading difficulties.

Materials and Methods: Thirty-seven children, aged 8 to 12

years, with reading difficulties, attended a multidisciplinary

reading clinic. Children completed literacy assessments de-

livered via a web-based application by a remotely located

research assistant. A teacher was stationed with the child and

coscored the assessments. Scores and qualitative observations

of the two assessors were compared.

Results: Spearman’s correlation analyses revealed strong

agreement between telepractice- and face-to-face-rated scores

(r = 0.79–0.99). Bland-Altman plots indicated excellent agreement between derived scores. Parents reported a high

degree of comfort with the telepractice assessments. Clin-

icians reported the audio and video quality was sound in

most cases.

Discussion/Conclusions: Web-based technology can enable

remote delivery of literacy assessments. The technology has

the potential to increase the availability of assessments to

meet the needs of children who live remotely, in a timely

manner and at their family’s convenience.

Keywords: telemedicine, behavioral health, education, telehealth,

pediatrics

Introduction

L iteracy difficulties are the most frequently diag-

nosed neurodevelopmental disorders in childhood

with prevalence estimates of 10–16% in the Australian

population.1–3 The impact of such difficulties on edu-

cation, employment, and mental health outcomes is well

understood.4–6 Identification of such difficulties through

standardized literacy assessments is therefore vital in deter-

mining the need for assistance, informing intervention plans7,

and reducing negative outcomes. Furthermore, such assess-

ments are necessary to evaluate the efficacy of, and pro-

vide feedback regarding, literacy interventions. Psychologists

and specialist teachers play an important role in the delivery

of literacy assessments. Unfortunately, access to such pro-

fessionals for children living in rural and remote areas is

limited by the lack of availability of those with specific ex-

pertise in the assessment of literacy difficulties. Furthermore,

the demand/need for these services is high for children in

rural/remote areas given that they consistently have poorer

academic performance than their urban counterparts.8,9 In-

deed, in the 2017 Australian National Assessment Program

Literacy and Numeracy report,10 the highest percentage of

children performing below the national standard for reading

attended schools in rural and remote locations.

Telepractice, or the use of information and communication

technologies to deliver services, may help improve access to

literacy assessments for children in distal geolocations. To

our knowledge, there have only been two studies that have

examined the use of telepractice in individuals with liter-

acy difficulties. In a 2016 feasibility study,11 two adults with

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phonological post-stroke reading difficulties showed im-

provements in their ability to read target words after a period of

intervention conducted remotely using videoconference tech-

nology. Waite et al.12 investigated the reliability of internet-

based assessments for 20 children aged 8–13 years, using

several standardized tests including the Queensland University

Inventory of Literacy, South Australian Spelling Test, and Neale

Analysis of Reading Ability.12 The results supported the reli-

ability of telepractice assessments, however, issues with audio

latency, break-up, and echo were noted. These issues made it

difficult for assessors to provide timely prompts and were a

distraction for participants. Furthermore, Waite’s study did not

examine participant and assessor acceptability of telepractice.

CURRENT PAPER The aim of the current paper is to help address the clinical

need for determining the feasibility and reliability of tele-

practice assessments. The limitations of the existing literature

indicated a need for additional high-quality research using

larger sample sizes, a wide range of the most current editions

of tests, and technology with improved audio and visual

quality. These limitations provided the impetus and rationale

for the current study, which examined a group of children

with learning difficulties. The study employed a comprehen-

sive battery of standardized psychometrically sound literacy

tests and involved clinical and teaching staff in real-world

settings who took an active role in the process of setting up the

remote assessment system as well as administering tests. The

equipment utilized in the current study consisted of consumer-

grade technology available for purchase at most office supply

stores and a flexible, web-based application. The current paper

aims to determine whether literacy assessments can be ad-

ministered reliably via remote testing compared with face-to-

face evaluation. The study also sought to obtain feedback from

teachers and parents in relation to the child’s behaviors and

about their satisfaction with telepractice.

Materials and Methods ETHICS AND PERMISSIONS

This study was approved by The Sydney Children’s Hospital

Network (LNR/16/SCHN/488) Ethics Committee and the New

South Wales (NSW) Department of Education. All eligible

children and parents or care providers, seen in the NSW Centre

for Effective Reading (the Centre), were approached, and only

those who signed informed consent were included.

SELECTION AND DESCRIPTION OF PARTICIPANTS Thirty seven children (n = 37) presented to the Centre, a joint

NSW Department of Education and NSW Health initiative.

Assessments occurred between January and December 2017,

and participants ranged in age from 8 to 12 years. Children

with a diagnosis of Specific Learning Disorder with impair-

ment in reading, who agreed to participate, were included.

There were no exclusion criteria based on intellectual ability

or language level.

TELEPRACTICE TECHNOLOGY The assessments were delivered via a web-based applica-

tion, ‘‘Coviu,’’ developed by the Commonwealth Scientific

and Industrial Research Organisation in Australia, which uses

peer-to-peer communication with full encryption, synchro-

nized image viewing, remotely visible click-markers for

pointing at images, and videoconference functionality. In-

expensive modern high-quality webcams and speakers were

used, along with commercial touch screens and standard-

issue computer equipment used in schools and in the hospital

where the research was conducted.

MEASURES Permission was granted for the use of copyrighted test

material by the copyright holders of the tests. Pearson Aus-

tralia Group Pty Ltd. (Woodcock Reading Mastery Test-III),

MultiLit Pty Ltd. (MultiLit Sight Words and MultiLit Word

Attack), Dalwood Assessment Centre (Dalwood Spelling Test

[DST]) and Pro-Ed, Inc. (TOWRE-2). With this permission, all

of the test materials were scanned and digitized for use in the

telepractice sessions.

Woodcock Reading Mastery Tests-Third Edition. The Woodcock

Reading Mastery Tests-Third Edition (WRMT-III)13 is a

norm-referenced assessment that measures several aspects

of reading achievement. It provides information about an

examinee’s reading performance that can be used to de-

velop effective, individually tailored reading intervention

programs. For the purposes of the assessment, the following

subtests were administered: Word Identification, a measure

of sight-word vocabulary; Word Attack, which measures

the ability to decode unknown words; Passage Compre-

hension which measures an individual’s ability to read and

understand a short passage by asking them to supply a

missing word.

Test of Word Reading Efficiency-Second Edition. The Test of

Word Reading Efficiency-Second Edition (TOWRE-2)14 pro-

vides an efficient means of monitoring the development of

two different word reading skills that are critical in the de-

velopment of overall reading ability. The Sight Word Effi-

ciency subtest measures a child’s ability to recognize familiar

words as whole units or sight words. The Phonemic Decoding

HODGE ET AL.

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Efficiency subtest measures a child’s ability to sound out

words quickly and accurately. The Pearson correlation coef-

ficient based on independent scoring of a subset of protocols

drawn from children in the normative sample was 0.99, pro-

viding evidence supporting the test’s inter-scorer reliability.

MultiLit. The MultiLit Sight Words Test15 includes 200

words that have been identified as being high frequency words

in the reading material of primary school aged children. The

ability to read a number of words by sight facilitates reading

fluency, which impacts comprehension.

The MultiLit Word Attack Test assesses a child’s letter-

sound knowledge and blending skills (single letters and letter

combinations) as well as the ability to apply this knowledge to

reading unfamiliar words.

Dalwood Spelling Test. The DST16 is a standardized test of

spelling achievement for children from kindergarten to year

10. It has been designed to provide a fast and reliable means of

identifying children with spelling weaknesses and for evalu-

ating skill progress over time.

Surveys

(i) Parents or carers completed a brief survey indicating the

perceived comfort level of their child during the assess-

ment as well as their own comfort level. There were

questions requiring both a response on a Likert scale and

an open-ended question to provide the parent or carer

the opportunity to express additional thoughts or to

provide feedback regarding the telepractice assessment.

(ii) Face-to-face teachers completed a project feedback

form, which addressed the child’s behavior and perfor-

mance during the assessment. Teachers were asked to

provide ratings on a Likert scale and make comments

regarding compliance, anxiety, attention and fatigue. In

addition, their thoughts around the use of technology,

including the visual and audio quality throughout the

assessment, and other comments were solicited.

DELIVERY METHOD The study involved children undergoing assessment that

was delivered via a web-based application by a research as-

sistant (RA). The children were located remotely (in Dubbo,

Wagga Wagga, Westmead, or Manly) and accompanied by

local staff (face-to-face teacher). The RA (online) leading the

test administration was located in Westmead, NSW. The RA

interacted with the child remotely and presented test items.

Scoring of the items was completed simultaneously by the RA

and the face-to-face teacher.

The order of test administrations was randomized. The RA

and the face-to-face teacher independently scored the as-

sessments as they were delivered. This simultaneous scoring

allowed for comparison of the ratings obtained in each en-

vironment while eliminating the test–retest or test learning

effects that may have occurred if the child was assessed on two

separate occasions.

TRAINING OF STAFF The study investigators included an RA (psychologist) and

teachers with modest experience in technology. The investi-

gators were trained and familiarized with the equipment and

study procedures in one session. A manual was also developed

for support staff to facilitate the telepractice assessments.

STATISTICAL ANALYSIS The independent variable in this phase was the condition

under which the assessment was conducted (telepractice vs.

face-to-face). The dependent variables were: (i) number of

sessions completed and local staff ratings of audio and visual

quality, which provided a measure of feasibility; (ii) the lit-

eracy assessment scores given by the online and face-to-face

staff, which were compared to provide a measure of reliability;

and (iii) behavioral observation scores made by the local staff

and RA which provided a measure of the tolerability of the

Coviu application.

The agreement between the telepractice and face-to-face

scores was examined using Bland–Altman measures of agree-

ment.17 Spearman’s correlation was used to provide measures

of correlation (interrater reliability) for standard scores. Parent

and teacher survey data were analyzed qualitatively.

Results Thirty-seven children underwent literacy assessments with

the RA administering eight assessments to each student. The

assessment generally took 40–60 min to administer. The me-

dian age of participants was 10 years 1 month (age range 8–11

years), and 20 participants were male. All children were

enrolled in regular mainstream classes. The median school

year was 4 (range 2–6 years). Ten of the 37 children had a co-

occurring diagnosis of attention-deficit/hyperactivity dis-

order (ADHD) confirmed by a pediatrician (23rd author).

Scores determined by the face-to-face teachers were taken as

the gold standard in the comparisons. On average, children’s

age equivalent scores on the WRMT-III Passage Compre-

hension (face-to-face) was 2.52 years below their chron-

ological age.

Table 1 depicts the Spearman’s correlation coefficients

comparing the scores of the RA to the face-to-face teacher.

LITERACY ASSESSMENT VIA TELEPRACTICE

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Spearman’s correlation analyses revealed very strong

agreement between telepractice and face-to-face rated

scores for all but one test. The test that yielded the lowest

agreement nonetheless fell at the upper end of the strong-

agreement range based on Spearman’s correlation coefficient

interpretation guidelines.18

On some occasions, there were technical difficulties

(thought likely to be due to insufficient bandwidth avail-

ability) leading to problems setting up the document camera,

temporary screen freezing, the need to refresh the Coviu

connection, or restart the browser. Although these difficulties

caused slight delays in telepractice assessment, they did not

prevent valid completion of the evaluation.

The analysis procedure proposed by Altman and Bland17

allows the visualization of the mean differences and the ex-

treme limits of agreement (–1.96 standard deviation of the difference) presented by the remote and face-to-face scores.

Bland–Altman plots (Fig. 1) indicated that, in general, the

mean differences between face-to-face and videoconference

modes of assessment were generally small with the largest

standard score discrepancy being 14 points in the TOWRE

Phonemic Decoding subtest.

Assessors reported high levels of comfort regarding the use

of telepractice to deliver assessments. Many of the open-ended

statements relating to the telepractice assessment experience

reflected a high degree of acceptability. Parents of participants

reported overall positive behaviors in the children (see Table 2

for a sample of responses).

Discussion The current study, the largest of its kind to date, extends

prior research and demonstrates the feasibility, reliability, and

acceptability of telepractice literacy assessments. A high level

of agreement between literacy assessments conducted face-

to-face and via telepractice was found, similar to the results of

the study conducted by Waite et al.12 The reliable, remote

evaluation of literacy skills is important to clinicians and

teachers who work with children with literacy difficulties for

at least two reasons: (i) such difficulties are common, and

many children living remotely do not have easy access to

assessments, and (ii) children who have completed an inter-

vention program can have postintervention assessments

conducted in a timely, standardized, and consistent manner.

The correlations between face-to-face and telepractice

evaluations were slightly lower for the MultiLit Word Attack

Test (placement level) compared with other literacy scores in

our study (Spearman’s correlation coefficient of 0.79 compared

with others at 0.86 and, most generally, above 0.95). The lower

agreement may be due to the less than ideal audio quality

necessary to hear the child’s reading of nonwords partly due to

the child’s position relative to the microphone which was em-

bedded in the webcam. This positional issue problem may have

been compounded when decoding nonwords, a task which

may have evoked higher anxiety in children with reading

difficulties and which may have led to clarity difficulties.

This study has several strengths, including a larger sample

size than the telepractice studies published to date, inclusion of

participants with a relatively wide range of intellectual abili-

ties (some with comorbid diagnoses of ADHD), and use of the

most recent versions of literacy tests. This study demonstrated

real-world use of consumer grade materials and thus may

have immediate applications in other real-world contexts.

Table 1. Spearman’s Correlation Coefficients Comparing Scores from the Online to Face-To-Face Administration Modes

COMPOSITE

SPEARMAN’S CORRELATION COEFFICIENT

r

SIGNIFICANCE (TWO-TAILED)

P-VALUE

Multilit Sight Words raw 0.947 <0.01

Multilit Word Attack PL 0.793 <0.01

Dalwood Spelling raw 0.997 <0.01

WRMT Word ID SS 0.985 <0.01

WRMT Word Attack SS 0.962 <0.01

WRMT Passage Comp SS 0.988 <0.01

TOWRE SWE SS 0.987 <0.01

TOWRE PDE SS 0.859 <0.01

SPEARMAN’S CORRELATION

NO ADHD r

SPEARMAN’S CORRELATION

ADHD r P-VALUE

Multilit Sight Words raw 0.934 0.918 <0.01

Multilit Word Attack PL 0.767 0.811 <0.01

Dalwood Spelling raw 0.996 0.998 <0.01

WRMT Word ID SS 0.984 0.971 <0.01

WRMT Word Attack SS 0.945 0.988 <0.01

WRMT Passage Comp SS 0.988 0.957 <0.01

TOWRE SWE SS 0.986 0.990 <0.01

TOWRE PDE SS 0.875 0.862 <0.01

WRMT, Woodcock Reading Mastery Tests; TOWRE, Test of Word Reading

Efficiency; ADHD, attention-deficit/hyperactivity disorder.

HODGE ET AL.

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Fig. 1. Bland–Altman plots and scatterplots illustrating interrater agreement and reliability across subtests. TOWRE-2, The Test of Word Reading Efficiency-Second Edition; WRMT-III, The Woodcock Reading Mastery Tests-Third Edition.

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Fig. 1. (Continued).

6 TELEMEDICINE and e-HEALTH M O N T H 2 0 1 8 ª M A R Y A N N L I E B E R T , I N C .

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To our knowledge, this is one of two studies of remote lit-

eracy assessments in children with literacy difficulties using a

comprehensive battery of tests and with typical assessors of

literacy tests who have modest technological knowledge. This

study collected rich qualitative data that extended beyond

face-to-face versus telepractice assessment score compari-

sons. Demonstrating the reliability of literacy assessments

conducted via web-based technology has the potential to

extend the reach of such assessments to children in remote

locations nationwide. It is hoped that this approach will be

adopted more widely to increase access to these valuable

assessments, thereby increasing equity to our rural and re-

mote population.

The limitations of the study should be considered when

interpreting these results. We obtained a convenience sample.

The enrolment of participants was selective for children who

have significant literacy difficulties who have not responded

to universal and targeted interventions. The generalizability

of the results to children with milder or no difficulties is un-

clear, given that the selection was not from the general pop-

ulation. The study should be replicated in more diverse groups

to ensure that results are easily generalizable to the broader

population. Although our study found high ratings overall for

the quality of audio and visual aspects of the web-based

technology, there were occasional technical issues based

around connectivity (suboptimal bandwidth). These technical

Fig. 1. (Continued).

LITERACY ASSESSMENT VIA TELEPRACTICE

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issues were characterized by slow connections, lags in re-

sponses, and dropped calls and were addressed by providing a

dedicated broadband cable connection and increasing the

bandwidth for multiple users. Dedicated connections need to

be considered when including web-based technology as a

service delivery option. This technology may not always be

possible for all services and organizations, given the potential

costs. The remote location of the assessor also presents chal-

lenges. This person cannot directly manage a child’s behavior

or activities, and so an individual is needed to be present on

site to support the child, for example, to provide certain

physical materials when needed or provide behavioral man-

agement when the child is having difficulties engaging in

tasks or loses concentration. It is interesting to note that, in

our study, there were minimal negative effects on concen-

tration, level of engagement, and participation in the tele-

practice assessments even in children diagnosed with ADHD.

Regardless, in the event of technical difficulties, it is essential

to have troubleshooting information and contingency plans

available to allow the assessments to be validly completed.

Conclusions Our study indicates that web-based technology can allow

assessments of literacy skills to be conducted remotely. This

technology has the potential to increase the availability of

assessments to meet the ever-growing need to support chil-

dren who live remotely from services, in a timely manner, and

at their family’s convenience. Telepractice has the potential to

improve time and caseload management efficiency therefore

resulting in more cost-effective service delivery. In our model,

telepractice assessment required a second person to be present

next to the child in each remote location to help with equip-

ment positioning. Whether another staff member, such as a

teacher’s aide or nonteaching staff, would be able to serve in

this role may impact the ultimate efficiency and cost savings

of implementing the telepractice. In addition, ethical and

privacy issues regarding the exposure of test materials and

confidential results to untrained individuals need to be taken

into consideration.

Acknowledgments This study was funded by the NSW Department of Educa-

tion. The Department was involved in discussions on the design

of the study, editing flow charts, planning the information

and consent forms, and preparing the social stories.

Disclosure Statement S.P. is the CEO of Coviu, the Web-based technology used in

this study, which may pose a competing financial interest in

the results of the submitted manuscript. The remaining authors

do not have any commercial associations that might create a

conflict of interest in connection with the submitted manuscript.

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Table 2. Parent Comments from the Satisfaction Survey Regarding the Telehealth Assessment

PARENT COMMENT

3 It’s a great idea for families not from Sydney. (Child) loved

the touch screen.

5 (Child) really enjoyed working with (RA) and using computer. I

like (RA)’s positivity and encouragement.

10 Great Idea!! My son was very excited to do it and really enjoyed it.

Commented on the way home it was ‘‘Awesome.’’ Thanks.

12 (Child) enjoyed doing it on the screen. She said she could clearly

understand what to do. (RA) was nice.

45 (Child) really liked the remote assessment. She appeared

comfortable and relaxed during the assessment and did not

have any concerns. I believe the remote assessment would

be beneficial for remote children.

RA, research assistant.

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16. Dalwood Assessment Center, ed. Dalwood spelling test/Dalwood Assessment Centre. Seaforth, NSW: Dalwood Assessment Centre, 2008.

17. Altman DG, Bland JM. Measurement in medicine: The analysis of method comparison studies. Statistician 1983;32:307–317.

18. Cohen J. Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Earlbaum Associates, 1988:20–26.

Address correspondence to:

M. Antoinette Hodge

Child Development Unit

The Children’s Hospital at Westmead

Hawkesbury Road

Westmead, NSW 2145

Australia

E-mail: [email protected]

Received: February 26, 2018

Revised: April 5, 2018

Accepted: April 6, 2018

Online Publication Date: July 24, 2018

LITERACY ASSESSMENT VIA TELEPRACTICE

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