Systematic Review

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International Journal of Speech-Language Pathology

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School-based language screening among primary school children using telepractice: A feasibility study from India

Nitya Raman, Roopa Nagarajan, Lakshmi Venkatesh, D. Saleth Monica, Vidya Ramkumar & Mark Krumm

To cite this article: Nitya Raman, Roopa Nagarajan, Lakshmi Venkatesh, D. Saleth Monica, Vidya Ramkumar & Mark Krumm (2019) School-based language screening among primary school children using telepractice: A feasibility study from India, International Journal of Speech-Language Pathology, 21:4, 425-434, DOI: 10.1080/17549507.2018.1493142

To link to this article: https://doi.org/10.1080/17549507.2018.1493142

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International Journal of Speech-Language Pathology, 2019; 21: 425–434

School-based language screening among primary school children

using telepractice: A feasibility study from India

NITYA RAMAN 1 , ROOPA NAGARAJAN

2 , LAKSHMI VENKATESH

2 ,

D. SALETH MONICA 3 , VIDYA RAMKUMAR

2 & MARK KRUMM

4

1 Pediatric Neurodevelopmental Centre and Autism Intervention Centre, Lokmanya Tilak Municipal Medical

College & Government Hospital (LTMMC & GH), Mumbai, India, 2 Department of Speech, Language and

Hearing Sciences, Sri Ramachandra University, Chennai, India, 3 Kaumaram Prashanthi Academy, Tirupur,

India, and 4 Department of Hearing Sciences, Kent State University, Kent, OH, USA

Abstract

Purpose: This study explored the feasibility of conducting school-based language screening using telepractice to expand its scope for providing speech-language pathology services in India. Method: Thirty-two primary school children underwent language screenings through in-person and telemethods. Screening through telemethod was conducted by a Speech-Language Pathologist (SLP) using digitised picture stimuli presented through videoconferencing and remote computing with assistance of a facilitator at school site. Technology and child- related factors influencing screening were documented using an inventory. Result: Language outcomes through in-person and telemethods revealed no significant differences in both receptive and expressive domains, suggesting absence of bias due to testing method used. Use of multiple internet options at both sites helped overcome technical challenges related to connectivity during screening through telemethod. The trained facilitator played a crucial role in overcoming child related factors such as poor speech intelligibility, poor audibility of voice, motivation, interaction with SLP and need for frequent breaks. Conclusion: Feasibility of conducting school-based language screening using multiple internet options and help of a facilitator at school demonstrates promise for delivery of services by SLP in resource constrained contexts such as India.

Keywords: Language; telepractice; screening

Introduction

Children’s speech and language development often

serve as an indicator for determining their overall

development and specifically foundational skills for

the development of literacy skills in school (Preston

et al., 2010). Early identification of speech and

language disorders in children followed by early

intervention substantially improves their communi-

cation development (American Speech-Language-

Hearing Association, 2008). There is a dearth of

developmental surveillance programmes for early

identification of developmental disorders in coun-

tries such as India (Kaur et al., 2006). The age at

entry to school may be an optimal point for

conducting screening leading to early identification

of speech and language delay or disorders among

children. School-entry level screening helps in iden-

tifying children who require support for speech and

language development and further special education

services in their later years (Hamilton, 2006).

School-based screenings provide access to large

groups of children between the ages of five years

and above.

There has been a significant increase in access

and enrolment of children at the primary schools in

India due to the increased efforts towards achieving

universal elementary education across the country

(Ministry of Human Resource Development, 2011).

Children enter primary schools between five and

seven years of age irrespective of presence or absence

of pre-school experience. Recent constitutional pro-

visions and mandates (e.g. The Right of Children to

Free and Compulsory Education Act, 2009) imple-

mented through several initiatives including govern-

ment-funded programmes (e.g. ‘‘Sarva Siksha

Abhiyan’’ or ‘‘Education for all’’ campaign) have

enabled progress in this regard. Implementing

school entry level screenings across all primary

Correspondence: Roopa Nagarajan, Department of Speech, Language and Hearing Sciences, Sri Ramachandra University, Chennai, India. Email:

[email protected]

ISSN 1754-9507 print/ISSN 1754-9515 online � 2018 The Speech Pathology Association of Australia Limited Published by Informa UK Limited, trading as Taylor & Francis Group

DOI: 10.1080/17549507.2018.1493142

schools pose several challenges. A few critical bar-

riers to the provision of school-based screenings by

Speech-Language Pathologists (SLPs) include non-

availability of trained professionals and the limited

ratio of SLPs to children requiring speech and

language assessments. The lack of accessibility to

service providers is another common barrier. The

implementation of telepractice as an alternate mode

of service delivery by SLPs may serve to overcome

these barriers (Theodoros, 2012).

The use of telepractice for providing both evalu-

ation and intervention services in the field of

paediatric speech-language pathology has been

explored. In a series of studies, Waite et al. reported

the use of telepractice to assess different aspects of

speech (Waite, Cahill, Theodoros, Busuttin, &

Russell, 2006), language (Waite, Theodoros,

Russell, & Cahill, 2010a) and literacy skills (Waite,

Theodoros, Russell, & Cahill, 2010b). Waite et al.

(2006) explored the feasibility of assessment of

childhood speech disorders through an Internet-

based telehealth system. Six children were tested and

scored on single-word articulation, intelligibility and

oro-motor structure and function, through in-person

and telemethods. High levels of agreement were

obtained between the two scoring environments.

Waite et al. (2010a) assessed 25 children in the age

range of 5–9 years using the Clinical Evaluation of

Language Fundamentals-4th Edition (CELF-4;

Semel, Wiig, & Secord, 2003). The scores obtained

through in-person testing corresponded well with

scores obtained through telemethod validating inter-

net based telemethod of language assessment among

children. Appropriate modifications of technology

(e.g. recording of responses at times of poor audio

and video quality) were made to suit assessment

needs as warranted (Waite et al., 2010a). Similar

results were reported in the evaluation of telepractice

for literacy assessments (Waite et al., 2010b).

Twenty children were tested on eight sub-tests of

the Queensland University Inventory of Literacy

(QUIL; Dodd, Holm, & Oerlemans, 1996), South

Australian Spelling Test (SAST; Westwood, 2005)

and the Neale Analysis of Reading Ability-3rd

Edition (Neale-3; Neale, 1999), simultaneously

through the conventional in-person method and

telemethod. The scaled scores obtained through in-

person and telemethods of testing demonstrated

good agreement, with most of the raw scores falling

within the predetermined clinical criteria (Waite

et al., 2010b). The use of low-cost video conferen-

cing (using Skype) for speech, language and hearing

screening of 25 young children in urban community

health clinics was found to be feasible, reliable and

also strongly supported by the community, with high

levels of satisfaction reported for technology and

video conferencing (Ciccia, Whitford, Krumm, &

McNeal, 2011).

Telepractice is a recommended form of service

delivery for screening, diagnostic and intervention

services for speech and language disorders in remote

areas (American Speech-Language-Hearing

Association, 2013). However, telepractice applica-

tions for provisions of SLP services in India are

limited mainly to anecdotal reports on providing

speech and language therapy for persons in distant

areas by use of teletechnology (Annual Report: All

India Institute of Speech and Hearing Mysore,

2012; Goswami, Bhutada, & Jayachandran, 2012).

Intervention delivered through telemethod for a

person with Broca’s aphasia resulted in significant

improvements in domains of repetition, naming,

fluency and memory as well as overall communica-

tion skills and emotional well-being (Goswami et al.,

2012). In contrast to SLP services, there have been

several attempts to explore telepractice application

for provision of audiological services in India (e.g.

Ramkumar, Hall, Nagarajan, Shankarnarayan, &

Kumarvelu, 2013; Ramkumar, John, Selvakumar,

Vanaja, Nagarajan, & Hall, 2018; Ramkumar,

Nagarajan, Kumarvelu, & Hall, 2014). Auditory

Brainstem Response (ABR) recordings obtained

remotely using satellite connectivity for newborn

infants demonstrated high levels of agreement with

direct recordings (Ramkumar et al., 2013). Research

on the use of satellite connectivity for the provision

of diagnostic hearing testing of infants in India

reported challenges in the availability of stable Local

Area Network (LAN) and Direct Subscriber Line

(DSL) based internet in rural areas (Ramkumar

et al., 2014).

India has witnessed a quantum increase in

internet penetration through mobile networks and

phones in comparison to the fixed LAN-based

internet in both rural and urban areas (KPMG-

IAMAI, 2015). Indeed, such an increase in internet

penetration supports the expansion of e-Health and

m-Health applications using teletechnology in-turn

leading to fundamental changes in service delivery

models in India (Ganapathy & Ravindra, 2008). The

term e-Health subsumes a broad range of

‘‘. . .healthcare practices supported by electronic processes and communication’’ while m-Health

refers specifically to the application of ‘‘. . .mobile communication devices, such as mobile phones,

tablet computers and PDAs for health services and

information’’ (American Telemedicine Association,

2016). Expansion of e-Health and m-Health across

India has opened new avenues to extend speech-

language services to remote areas using telepractice.

A recent study on the application of telepractice

on hearing assessments demonstrated the feasibility

of using mobile hotspots and dongle-based internet

for conducting hearing screenings within a school

setting (Monica, Ramkumar, Krumm, Raman,

Nagarajan, & Venkatesh, 2017). Hearing thresholds

obtained for 5- to 8-year-old children using testing

through telemethod and in-person method were

similar. The current study was planned as a com-

panion study to research by Monica et al. (2017) to

426 N. Raman et al.

explore the feasibility of conducting language

screenings in a school by an SLP through teleprac-

tice. It is vital to identify technology-related chal-

lenges in the implementation of telepractice in

language screening and how local conditions may

be improvised to facilitate successful implementa-

tion. Exploring feasibility for school-based screen-

ings is the first step in understanding and expanding

the scope of use of telepractice for the provision of

detailed diagnostic and intervention services in

speech-language pathology. Specific aims of the

study were to (1) compare receptive and expressive

scores obtained on a language screening tool

through in-person testing and telemethod among

children and (2) to assess technology- and child-

related factors influencing screening via telemethod.

Method

The study underwent a complete review and was

approved by the Institutional Ethics Committee of

the University.

Participants

A group of 32 children from grade 1 (age: M¼6;3 years; SD¼0.58; 95% CI¼2.38) in a primary school located in Tirupur town, 400 kilometres

from hospital site at Chennai city (both locations

within the southern state of Tamil Nadu in India)

participated in the study. Informed consent was

obtained from parents of all participants. All chil-

dren provided verbal assent to participate in the

study. Teachers of two classrooms of children in first

grade completed a screening checklist (Venkatesh &

Cherian, 2015) with 22 ‘‘yes/no’’ questions on

hearing, speech, language and academic concerns

in children before their recruitment into the study.

Fifteen children identified by teachers as having

concerns in one or more areas of hearing, speech,

language or academics were included in the study. In

addition, 17 children with no specific concerns in

the hearing, speech, language or academic perform-

ance by the teachers and parental consent for

participation in the study were selected randomly

from the same classrooms.

Personnel

Two trained SLPs completed language screenings

for children through in-person and telemethods.

Both the SLPs had completed an undergraduate

degree with similar training in an institution

recognised by the Rehabilitation Council of India

(RCI). The SLP carrying out in-person screening

was located at the school site, and the SLP carrying

out screening through telemethod was housed at the

hospital site. A primary grade teaching assistant

designated by school authorities was trained to serve

as a facilitator and assist the child in screening

through telemethod. All personnel including the

teachers completing the screening of children prior

to recruitment, teaching assistant designated as a

facilitator and the SLPs were duly qualified and

certified as per the requirements for their respective

professional practice in India.

Testing tool

The Assessment of Language Development (ALD;

Lakkanna, Venkatesh, & Bhat, 2008) was used for

language screening. ALD is a criterion-referenced

measure and was developed to serve as a language-

neutral test with items based on universals in

language development (Lakkanna et al., 2008).

The test includes items for receptive and expressive

language skills from birth to 7;11 years of age. The

items encompass aspects of language including

vocabulary, syntax, semantics and thinking/reason-

ing skills. Items are grouped into six-month intervals

from birth to three years of age and one-year

intervals from three to eight years of age. There are

four to eight items for receptive language across the

different age groups. The total number of items

range from three to eight for expressive language

across the different age groups. Each item is scored

as ‘‘zero’’ or ‘‘one’’ depending on the child’s

performance specific to requirements for each

item. The results of the test are interpreted by

comparing the scores obtained for reception and

expression against an 80% criterion set for any

particular age level to determine if a child’s receptive

and expressive language skills are ‘‘age appropriate’’

or ‘‘delayed’’. The test developers selected an 80%

criterion level to avoid chance factor (50%) and a

stringent criterion of 100%. The current study used

ALD considering its applicability to children speak-

ing varied languages, a typical scenario in a multi-

lingual country such as India. Further, considering

the limited number of items within each group and

the lack of psychometric data on the properties of

ALD for diagnosis of language impairment, the test

was used as a screening tool in the current study.

Appropriate permission and consent were

obtained from the test developers to digitise the

picture stimuli and present the pictures arranged

within a PowerPoint� presentation through a laptop,

for in-person and telescreenings. Receptive language

screening required children to point to picture

stimuli presented on the laptop screen. Expressive

language screening required children to provide a

verbal response to picture stimuli and questions by

the examiner. The test protocol entails commencing

the test with test items one year below the chrono-

logical age of the child. In the current study, testing

began for all children with items in the age range of 4

to 4;11 years, months. All children passed the first

three items consecutively within this age range to

establish the basal score. Testing was discontinued if

a child failed to perform five consecutive items. The

total scores in terms of the total number of items

Tele-language screening in school 427

passed in the receptive language and expressive

language domains were calculated for each child.

Performance of each child in terms of ‘‘age appro-

priate’’ or ‘‘delay’’ was determined in the receptive

and expressive language domains against an 80%

pass criterion level, as prescribed in the test manual.

An inventory to document child and technology-

related factors were developed to assess their impact

on the testing process and outcome. The questions

were developed based on factors listed in a study

conducted to assess language in children (Waite

et al., 2010a). Child-related factors included motiv-

ation and attention of child during testing; sustained

interest in stimuli; audibility of child’s voice while

responding; interaction with the online (remote)

clinician and requirement of frequent breaks during

screening. Technology related factors documented

included disruptions in connectivity; lag in audio/

video output; transition of picture stimuli, back-

ground lighting, noise levels in the testing room and

presence of any other disturbances which affected

the performance of the child. Questions were

developed based on relevance to school settings, in

consultation with two experienced SLPs in the field

of telepractice.

School environment/child-end environment

Both the examiners trained with the third author on

the administration of the test and scoring of

responses as prescribed in the test manual. The

training included simulated demonstrations and

mock screenings before carrying out actual screening

tests. The in-person and telemethod language

screenings were carried out in a single dedicated

space allocated within the school premises.

Adequate lighting, appropriate placement of furni-

ture to avoid distractions during testing and pos-

itioning of a child in front of laptop screen were

ensured before commencing testing. Picture stimuli

for the screening in-person and through telemethod

at the school site were presented through a laptop

(Sony Vaio� SVE11115EN). An external c615

Logitech� HD webcam was used for video confer-

encing. The webcam had features of remote access

and could be controlled using software by the

clinician at the remote hospital site. In addition,

features of pan, tilt and zoom in the webcam could

be controlled by the clinician at the remote site for

better visualisation of the child. Logitech� h110

stereo headsets with noise and feedback cancellation

were used by the examiner, facilitator and child

during interaction and testing process.

SLP-end environment setting/SLP-end

environment

A laptop (Dell� Inspiron N5110) at the hospital site

was used to remotely control the presentation of

stimuli from the laptop at the school site, using an

encrypted application sharing software (Team viewer

10). The examiner used a Logitech� h110 stereo

headset with noise and feedback cancellation at the

hospital site. A Wi-Fi hotspot was the first choice for

connecting the laptop to the internet at the school

site. However, when connectivity was reduced with

the Wi-Fi hotspot, a mobile hotspot tethered from

the phone with a 3G network to the laptop was used

instead. The laptop at the hospital site was con-

nected to the internet using the LAN connection

available at the hospital. At times of power failure or

non-availability of the LAN network, a plug-in

dongle was used instead. At both testing sites, the

internet sources were chosen based on the maximal

bandwidth provided by the provider. The upload

and download speeds of different service providers

were noted each day at the beginning and end of the

screening. The connection speeds of internet con-

nectivity are presented in Table I. Typically, band-

widths increased in order from plug-in dongles,

mobile hotspots, wired LAN and Wi-Fi hotspot.

Schematic representation of equipment setup at the

school and hospital sites is depicted in Figure 1.

Procedure

Training of facilitator. The facilitator was trained over

three days, prior to commencing the screening. The

training focussed on imparting four significant skills

including (a) manipulating testing environment

(positioning of child, monitoring ambient noise

levels, ensuring adequate lighting, etc.), (b) manip-

ulating technology (switching on laptop, connecting

to internet, placing headphones, troubleshooting

when loss in connectivity), (c) engaging child

during screening (ensuring child’s cooperation,

boosting child’s interest, etc.) and (d) documenting

behaviours of every child and technology-related

factors, influencing screening. The facilitator

observed the SLP carrying out a demonstration of

the screening process and conducted three screen-

ings under the supervision of SLP at the school

before undertaking the role independently.

Table I. Connectivity speeds of different internet options.

Range of connectivity speed

Internet connectivity options Upload speed Download speed

Service Provider A (plug-in dongle; 2G) 18 Kbps 6 Kbps Service Provider B (plug-in dongle; 3G) 614 Kbps 15.3 Mbps Service Provider C (mobile hotspot; 3G) 7.3 Mbps 23.3 Mbps Wired LAN 136 Mbps 136.62 Mbps Service Provider D (Wi-Fi hotspot; 3G) 36.9 Kbps to 314.2 Mbps 219 Kbps to 236.04 Mbps

428 N. Raman et al.

Language screening. Language screenings were

carried out in-person by the examiner at the school

site and through the telemethod by the examiner

located at the hospital site with assistance from

facilitator at the school site. All screenings were

completed over a period of three weeks. Both

screenings through in-person and telemethod were

carried out independently on the same day. Half the

number of children (n¼16) were assigned to undergo in-person screening first, and the other

half were assigned to undergo screening through

telemethod first. The examiners remained blinded to

the results obtained by each other. Informal screen-

ing and rapport building through general conversa-

tion was established prior to formal screening

through both methods. The estimated time for

completion of each individual screening was about

30 minutes. The actual time taken for completion of

in-person screenings and any significant observa-

tions/difficulties faced by the child during in-person

screening were noted by the examiner at the school

site. Similar observations were noted by the facilita-

tor as well as the examiner at the hospital site during

the screening through telemethod. The facilitator

oriented the child to the test procedure and set up,

ensured proper seating of the child and repeated

instructions wherever necessary or as directed by the

examiner at the hospital site. Whenever required, the

facilitator also read out the ‘‘letter code’’ under each

picture pointed to by the child in the receptive

domain to help the examiner score the child’s

responses. The facilitator documented child-related

and technology-related factors which may have

influenced the child’s performance using the obser-

vation inventory for each child.

Data analyses. Non-parametric statistics were

required for group comparison of scores obtained

between in-person and telemethod screenings.

Wilcoxon signed rank test was used for comparison

of scores between in-person and telemethod for both

receptive and expressive language domains. Bland–

Altman’s plots (Bland & Altman, 1986) were used

for assessing levels of agreement between the scores

(continuous data) obtained through the two meth-

ods. The Bland–Altman plots represent the means of

each pair of measurements (x value) versus the

difference between the measurements (y value).

Limits of agreement (mean difference �2 SD) between the two methods of administration were

determined as per the method by Bland and Altman

(1986) for assessing agreement between the meth-

ods. Individual scores for each child obtained

through screenings performed in-person and

through telemethod were compared for receptive

language, and expressive language domain with

reference to the clinical criteria provided for various

age ranges in the test.

Result

Comparison of scores of two methods

Wilcoxon’s test revealed no significant difference

[Z¼1.31, p¼0.19] between scores for receptive language obtained through testing in-person

(Mdn¼47.00, M¼46.56, SD¼3.87) and tele- method (Mdn¼47.00, M¼46.34, SD¼3.89). Similarly, there was no significant difference

[Z¼�1.09, p¼0.28] in scores for expressive lan- guage between in-person screening (Mdn¼49.00, M¼47.31, SD¼3.97) and telemethod screening (Mdn¼49.00, M¼46.34, SD¼3.89). Further comparisons of scores obtained through screenings

done in-person and through telemethod for recep-

tive and expressive language skills were made using

Bland–Altman’s plots (Figure 2(a,b)). The limits of

agreement (�2 SD) between the two methods for receptive language domain was –2.87 and 2.75.

Similarly, the limits of agreement between the two

methods for expressive language domain was –2.51

and 2.0. Visualisation of both plots revealed that the

scores between language screenings conducted in-

person and through telemethod were within two

standard deviations from the mean, except for two

values in the receptive domain and one value in the

expressive domain.

Both in-person and telemethod screenings identi-

fied the same two children (one child in the age

range of 5 to 5;11 years and another child in the age

range of 7 to 7;11 years) who obtained scores below

the 80% criteria for both receptive and expressive

domains. These children were noted to be at-risk of

having mixed receptive and expressive language

disorder and were referred for detailed assessment.

Figure 1. Schematic representation of equipment setup at the school and hospital sites.

Tele-language screening in school 429

Two other children demonstrated scores below 90%

of total scores for expressive language alone sug-

gesting risk for the presence of delay in expressive

language skills. These findings agreed with the

teachers’ referrals of these children as having con-

cerns in speech and language. In addition to

language delays, SLPs noted the presence of

speech sound errors in one child, speech dysfluen-

cies in one child, and both speech sound errors and

dysfluencies in one child during both telemethod

screening and in-person screening performed inde-

pendently. These errors were noted by the SLPs as

part of informal observations while interacting with

children and recording responses of the children

during the assessment of expressive language skills.

Technology- and child-related factors

influencing language screening through

telemethod

The technical factors influencing telemethod screen-

ing process are reported in Table II. The frequency

of occurrence reported in the table refers to the

number of sessions in which the behaviours were

observed. Bandwidth congestion was observed to be

maximal between 10 am and 12 pm, as compared to

other times of the day. This led to delay in audio

input and caused disruption in examiner’s instruc-

tions and presentation of stimuli, resulting in

prolonged testing time. Another important aspect

of consideration related to technology was ‘‘signal

drop’’ in connectivity during screening. Influence of

‘‘signal drop’’ was observed for one of the teleses-

sions where the child was not cooperative due to the

prolonged time for reconnecting to the internet. The

lag in the audio outputs at the school site due to

‘‘signal drop’’ further led to prolonged time for

testing, thereby interrupting child’s cooperation.

Another factor observed to have an influence on

screening was ambient noise levels. In a few

instances, there was an ongoing extra-curricular

class outside the testing room. This led to disturb-

ances in the clarity of examiner’s audio output

making it difficult for the facilitator and child to

follow the clinician’s instructions, at the hospital

end. The time taken for screening each child

through in-person and telemethod was recorded

during the testing procedure. This included time for

obtaining demographic details, rapport building

with the child and assessing the receptive and

expressive language domains. The median time

Figure 2. (a) Bland–Altman’s plot showing the difference and average of receptive scores for in-person and telemethods. (b) Bland–

Altman’s plot showing the difference and average of expressive scores for in-person and telemethods.

Table II. Summary of technical factors and their influence on screening through telemethod.

Technology related factors Frequency of occurrence Impact on screening

Audio lag Slight lag in audio output

21 No major effects on test proceedings

Connectivity Bandwidth congestion leading to dis- ruption of internet connectivity

15 Resulted in disruption in audio which delayed testing time by as much as 5–10 minutes in 7/15 sessions. One child was distracted and de-motivated to answer due to increased time for reconnecting.

Transition in picture stimuli Delay in transition of pictures from one slide to another

3 Increased time for completion of screening for three children (approx. 15 minutes longer)

Disturbance in testing room Teacher walked into the room

3 Children and facilitator faced difficulty in following instruc- tions from SLP at the hospital site.

Noise levels in testing room High levels of noise in environment, due to class conducted outside testing room

1 Child and facilitator faced difficulty in following instructions from SLP at the hospital site

430 N. Raman et al.

taken for screening via the in-person method was

25 minutes (Min¼15; Max¼40 min). The median time taken for screening via the telemethod was

35 minutes (Min¼20; Max¼85 min). An increased time taken through telemethod may have resulted

from the disruption in connectivity, the time for

reconnecting and audio/video lag.

Child-related factors influencing screening

through telemethod are reported in Table III. The

frequency of occurrence in the table refers to the

number of children in whom each factor was

observed. Speech intelligibility was found to be

poor in two children. These made it difficult to

record and decipher responses by the examiner at

the hospital site, especially for test items related to

expressive language. Also, soft voice of a child led to

difficulty in interpreting child’s responses. In such

situations, the facilitator was particularly helpful in

prompting and repeating the child’s utterances to the

examiner. Although speech intelligibility was

reduced for the two children even during in-person

screening, it was easier handled as the examiner had

an opportunity to interact directly with the child.

This enabled the examiner to observe the non-verbal

gestures, accompanying child’s verbal utterances.

This was in contrast to the telemethod, where

instances of ‘‘signal drop’’ in internet connectivity

led to poor video quality and hence posed a

challenge in observing non-verbal gestures. Other

factors which influenced screening through tele-

method included attention span of children and their

motivation to respond to stimuli. It was difficult to

sustain the motivation and attention span for two

children in both methods of screening. Two other

children needed frequent breaks. These behaviours

were observed in both methods of testing, irrespect-

ive of the order of testing, and were likely due to

poor attention spans of these children.

Discussion

Results reflected high levels of agreement between

scores obtained through in-person and telemethods

of language screening among primary school chil-

dren in the current study. These results agreed with

research conducted in Australia and USA, which

have established high levels of agreement between

in-person and telemethods for speech-language

assessments (Fairweather, Lincoln & Ramsden,

2016; Fairweather, Parkin, & Rozsa, 2004; Waite

et al., 2006, 2010a). These results suggested that

testing through the telemethod was conducive in

local school environments with mobile hotspot/plug-

in dongles, which provided adequate bandwidth

connectivity. Although the agreement between in-

person and telemethod was established in the

current study, the process was not without chal-

lenges. Several technical and child-related factors

affected the screening through telemethod.

Technology-related factors

Telepractice applications in speech-language path-

ology require stable and high-speed connectivity and

bandwidth. These are necessary for ensuring good

quality two-way video conferencing, to conduct

speech-language assessment or intervention effect-

ively. Earlier investigations have employed LAN

connection, as a standard steady source of internet

for video conferencing and telepractice (Ciccia et al.,

2011; Fairweather et al., 2016; Waite et al., 2010a).

The use of LAN connectivity is not a practical

solution considering the unavailability of LAN

within the Indian context. Therefore, alternate

internet connectivity options were explored in the

present study to ensure sustained speed and max-

imum bandwidth for quality assessments.

India has witnessed a phenomenal surge in

penetration of mobile technology in both urban

Table III. Summary of child related factors and their influence on screening through telemethod.

Child related factors Frequency of occurrence Impact on screening

Interaction with SLP Children did not request for clarification or repetition when there was an audio break up during the videoconference

5 It led to many ‘‘don’t know’’ answers from children. Facilitator prompted the child to ask for repetitions of questions that children did not know.

Speech intelligibility and audibility Children had low speech volume and poor intelligibility

3 The online clinician could not hear or understand the responses given by the children and score the responses especially during periods of loss of audio/video due to poor signal connectivity. In such cases, facilitator had to repeat the children’s responses to the online clinician.

Interaction with SLP Children did not request for clarification or repetition when there was an audio break up during the videoconference

5 It led to many ‘‘don’t know’’ answers from children. Facilitator prompted the child to ask for repetitions of questions that children did not know.

Attention and concentration Children was tired and distracted

2 Both children needed extra prompting to respond and needed frequent repetitions of questions.

Requirement for frequent breaks Children required breaks in between screening

2 Children took a long time (around 45 minutes) for completing screening and required additional coaxing and prompt to respond.

Tele-language screening in school 431

and rural areas with an estimated increase in mobile

phone users from 3.6 million users in the year 2012

to 213 million users in 2015 (Telecom Regulatory

Authority of India, 2015). It is expected, that this

number will further increase to 314 million, by the

end of 2017 (KPMG-IAMAI, 2015). The rapid

explosion of mobile platforms makes the use of

mobile internet a viable option in areas where

internet penetration is low, and bandwidth may not

be optimal. In the present study, internet through

smartphones was tethered to the laptop and used to

carry out teletesting. This study is one of the first

studies to explore language screening through

telepractice using internet from a mobile hotspot.

Internet connectivity through mobile hotspot func-

tioned like connectivity through a plug-in dongle,

Wi-Fi hotspot and LAN network for the current

study. Therefore, it is recommended to have several

internet options available for conducting telemethod

assessments to ensure maximally sustained

connectivity.

In addition to the availability of the internet,

increased bandwidth is also an essential technical

component of telepractice. Connectivity has been

reported as a significant contributing factor in the

effective testing of speech production through

telemethod (Mashima & Doarn, 2008; Waite et al.,

2010a). Planning screenings during times of the day

when optimal bandwidth was available helped over-

come issues related to connectivity. During

increased congestion in bandwidth, there was a

drop in the signal, leading to disruptions in video

and audio outputs, and audio lag. These, in turn, led

to increased or prolonged time for screening or

resulted in the child losing interest and not

cooperating for testing. These observations were

similar to the challenges recorded by Waite et al.

while assessing language among children, using

telepractice (Waite et al., 2006, 2010a). The role

of the facilitator was particularly crucial in such

times to ensure that the children were re-engaged in

the process to complete testing.

Child-related factors

A major child-related challenge observed during

testing via telemethod was speech intelligibility of

child. Such difficulties were reported in a study

exploring the feasibility of conducting language

assessment through telepractice (Waite et al.,

2010a). Research exploring the use of telepractice

has also reported speech intelligibility and audibility

of the child as an important contributing factor

(Fairweather et al., 2004; Jessiman, 2003; Waite

et al., 2010a). The interaction between examiner

and child was a significant factor to consider for

children who were shy. In some instances, the video

of the examiner at the hospital site was switched off

due to poor bandwidth and children could not

visualise the examiner at the hospital end. This

resulted in the child being reluctant to seek clarifi-

cations and ask for repetitions. Facilitator encour-

aged the child to seek appropriate inputs from the

examiner at the hospital end. These findings

emphasised the need to provide training to facilita-

tors in managing behavioural variations presented by

children. The attention span of the child and

motivation to respond to stimuli also affected

screening. These factors were recorded in both

methods of screening, irrespective of the order of

testing. It was easier for the SLP at the school site to

bring back child’s attention and re-engage the child

during in-person method with a little persuasion in

comparison to telemethod. The screening was

completed through telemethod with assistance

from the facilitator. Motivation, attention and con-

centration of child are important contributors for

successful implementation of teleassessments (Waite

et al., 2010a). A worthwhile solution to overcome

this challenge in testing through telemethod may be

to split the entire screening into two or three smaller

sessions to ensure the complete cooperation of child

throughout the testing process. Although screening

through telemethod required extended time in

comparison to in-person screening, the extended

time of testing did not affect test scores or perform-

ance of children.

Role of a trained facilitator in telepractice

Findings of the present study highlighted the crucial

role of facilitator in overcoming challenges posed by

factors related to technology and child on the

language screening through telemethod. Although

several challenges faced in the current study were

similar to those reported in other studies, effective

training of facilitator in overcoming these challenges

have not been widely reported. The use of a trained

facilitator is a relatively new concept in the field of

speech-language pathology. Earlier reports of assess-

ments using telepractice in schools have included

another clinician at school site or remote end to

manoeuvre equipment and assist child during testing

language (Ciccia et al., 2011; Fairweather et al.,

2016; Waite et al., 2010a) and speech (O’Brian,

Packman, & Onslow, 2008; Sicotte, Lehoux,

Fortier-Blanc, & Leblanc, 2003; Waite et al., 2006;

Wilson, Onslow, & Lincoln, 2004). Studies in

teleaudiology have explored the feasibility of training

an assistant at community site to assist in the

telemethod testing process (Krumm, Huffman,

Dick, & Klich, 2008; Lancaster, Krumm, Ribera,

& Klich, 2008). Facilitators must be trained to

effectively manipulate technology and manage

behavioural manifestations of children for successful

assessments. Further, findings of the current study

suggest that a teacher, a parent of a child from a

different classroom, or any other support staff from

school may be trained to act as a facilitator for such

telemethod sessions.

432 N. Raman et al.

Limitations and future directions. The current study

was limited to a language screening protocol. Future

research on the administration of more extended

diagnostic assessment protocols will provide insights

into additional factors for consideration in use of

telepractice for language assessments. Perceptions

and satisfaction of all stakeholders including chil-

dren, their families, and schools on the use of

technology for language screenings also need to be

assessed in future to improve the delivery of services.

Establishing the feasibility of using telepractice for

providing speech-language pathology services to a

remote area in India opens the avenues to expand

services within similar resource-constrained regions

around the world. For example, the use of internet

connectivity through mobile networks can be

explored in other regions with poor or limited

wired internet penetration.

Conclusion

The present study was a ‘‘proof of concept’’,

establishing the feasibility of using telepractice for

screening language among children in a school-

based setting in India. There was no clinically

significant difference in the results of language

screenings performed through in-person and tele-

methods. Language skills could be screened among

children as young as five years of age by an SLP

using telemethod with the help of a trained facilita-

tor at school. Internet connectivity through mobile

networks (mobile hotspot and dongles) served as

alternate methods to internet connectivity when

bandwidths of wired internet connectivity were

limited. Several technical and child-related factors

impacted few screening sessions and need to be

factored while planning and implementing such

screenings.

Acknowledgements

We thank Dr. Jayashree S Bhat for granting permission

to digitize the picture stimuli provided in the

Assessment of Language Development for use in the

study. We thank the school administrators and the

facilitator for their active participation.

Declaration of interest

No potential conflict of interest was reported by the

authors.

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