INT J LANG COMMUN DISORD, XXX 2016,

VOL. 00, NO. 0, 1–18

Research Report
Telehealth delivery of Rapid Syllable Transitions (ReST) treatment for
childhood apraxia of speech
Donna C. Thomas, Patricia McCabe, Kirrie J. Ballard and Michelle Lincoln
Faculty of Health Sciences, The University of Sydney, Lidcombe, NSW, Australia
(Received March 2015; accepted December 2015)

Abstract
Background: Rapid Syllable Transitions (ReST) treatment uses pseudo-word targets with varying lexical stress to
target simultaneously articulation, prosodic accuracy and coarticulatory transitions in childhood apraxia of speech
(CAS). The treatment is efficacious for the acquisition of imitated pseudo-words, and generalization of skill to
untreated pseudo-words and real words. Despite the growing popularity of telehealth as a method of service
delivery, there is no research into the efficacy of telehealth treatments for CAS. Telehealth service delivery is
associated with compromised audio and visual signal transmission that may affect the efficacy of treatment.
Aims: To conduct a phase 1 efficacy study of telehealth delivery of ReST treatment for CAS, and to discuss the
efficacy with reference to face-to-face ReST treatment.
Methods & Procedures: Using a multiple baseline across participants design, five children aged 5–11 years with
CAS received ReST treatment four times a week for 3 weeks via video conferencing with Adobe Connect. The
children’s ability to imitate new pseudo-words, generalize the skills to untreated pseudo-words and real word
items, and maintain the skills following treatment were assessed. Both visual and statistical analyses were utilized.
Outcomes & Results: All five children significantly improved with their production of the imitated treated pseudo-
word items and significantly generalized to similar untreated pseudo-words and real words. Additionally, two of
the children showed significant generalization to imitated phrases with the treatment items. Four of the children
maintained their treatment gains up to 4 months post-treatment. Telehealth delivery produced similar acquisition
of pseudo-words and generalization to untreated behaviours as face-to-face delivery; however, in the 4 months
following treatment, the children showed stable rather than improving speech skills. The intra- and inter-judge
reliability was similar in telehealth delivery for face-to-face delivery. Caregivers and clinicians were satisfied with
the telehealth treatment.
Conclusions & Implications: This phase 1 study provides promising indications of the efficacy of ReST treatment
when delivered four times per week via telehealth, and warrants further large-scale investigation.
Keywords: therapy, intervention, prosody, dyspraxia, video conferencing, Adobe Connect, telespeech, telepratice.

What this paper adds?

What is already known on the subject?
Telehealth is being increasingly used for assessment and treatment of communication disorders. This service delivery
method has demonstrated effectiveness for the treatment of many communication disorders, including articulation
and phonology impairments, but there is no information about the efficacy of telehealth treatments for CAS.
ReST treatment is efficacious for CAS when delivered face to face, producing the acquisition of new pseudo-words,
generalization to untreated skills and retention of skills following treatment. This phase 1 study investigates the
efficacy of ReST treatment for CAS when delivered by telehealth.

What this paper adds?

Preliminary support for the use of ReST treatment, when delivered four times per week via video conferencing. The
results justify larger scale studies of this service delivery method.

Address correspondence to: Donna Thomas, Discipline of Speech Pathology, Faculty of Health Sciences, The University of Sydney, PO Box
170, Lidcombe NSW 1825, Australia; e-mail: donna.thomas@sydney.edu.au
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online  C 2016 Royal College of Speech and Language Therapists

DOI: 10.1111/1460-6984.12238
2 Donna C. Thomas et al.
Introduction When provided in the client’s home, telehealth elimi-
nates the travel time associated with face-to-face therapy
Children with childhood apraxia of speech (CAS) have (Reynolds et al. 2009), and improves generalization
difficulty planning and programming the movements (Theodoros 2013). Telehealth is well accepted by
required for the production of accurate speech sounds families (Constantinescu 2012) and in some cases is
and prosody. Their speech is often characterized by in- preferable for clients over face-to-face delivery (Ciccia
consistent errors, inappropriate prosody and disrupted et al. 2011). Although the term ‘telehealth’ covers all
coarticulatory transitions (American Speech–Language– types of services mediated by technology, the focus of
Hearing Association 2007). The difficulties associated this article is video conferencing, which provides real-
with their impairment are often persistent (Lewis et al. time transmission of both audio and visual information.
2004) with potential effects in a range of linguistic and There is growing evidence supporting the use of
speech-motor domains (American Speech–Language– video conferencing for speech pathology (for reviews, see
Hearing Association 2007). It has been argued that Theodoros 2011 and Mashima and Doarn 2008). The
children with CAS require more intensive treatments effectiveness of video conferencing has been more widely
than other speech-sound disorders (Maas et al. 2014, investigated for assessments than for therapy. Video
Murray et al. 2014, Namasivayam et al. 2015), and for conferencing assessments produce equivalent results to
a longer period (Skinder-Meredith 2001). face-to-face assessments in several speech and language
Although several different treatments are used for areas, including paediatric speech-sound disorders
CAS, most have been investigated in case study or (Eriks-Brophy et al. 2008, Waite et al. 2012). Despite
case-series designs and have low levels of evidence the promising results from speech-pathology assessment
regarding their effectiveness (Murray et al. 2014, Maas of speech-sound disorders using video conferencing,
et al. 2014). Rapid Syllable Transitions (ReST) is a poor inter-rater reliability has been shown between face-
relatively new treatment for CAS that uses pseudo-word to-face and telehealth assessments for the identification
targets with varying lexical stress patterns to target of the presence or absence of voicing, accuracy of frica-
simultaneously articulatory accuracy, fluent transitions tive phoneme perception, identification of phonemes
between syllables and lexical stress. ReST incorporates without visible articulation (e.g., /tʃ/ and /l/) (Eriks-
motor learning principles to facilitate retention and Brophy et al. 2008, Waite et al. 2006), and perception
generalization of treated skills. ReST treatment has of abnormal nasal resonance in speech (Hill et al. 2006).
demonstrated an improvement in treated items (Ballard Video conferencing as a service delivery model is
et al. 2010, Thomas et al. 2014), generalization of treat- showing promising results for speech-pathology treat-
ment effects to untreated pseudo-words (Ballard et al. ments, particularly treatments that are operationally
2010, Thomas et al. 2014), and to connected speech defined. Effective treatment via video conferencing
(Staples et al. 2008). A randomized controlled trial has been demonstrated for the Lidcombe Program
comparing ReST treatment with the Nuffield Dyspraxia for stuttering (O’Brian et al. 2014), the Camperdown
Programme—Third Edition, demonstrated the efficacy Program for stuttering (Carey et al.2014), and the Lee
of both treatments (Murray et al. 2015). Specifically, R
Silverman Voice Treatment (LSVT ) for patients with
ReST treatment resulted in significant acquisition of Parkinson’s disease (Constantinescu et al. 2011).
treated pseudo-words, significant generalization of treat- Articulation impairments have been effectively
ment effects to untreated pseudo-words and real words, treated via video conferencing. In a series of stud-
and maintenance of treatment effects for 4 months ies culminating in a randomized controlled trial,
post-treatment (Murray et al. 2015). Although typically traditional articulation therapy was shown to be as
delivered across four 1-h sessions per week for 3 weeks, effective via video conferencing as face-to-face delivery
ReST is also efficacious when provided across two 1-h (Grogan-Johnson et al. 2013). The participants in
sessions per week for 6 weeks (Thomas et al. 2014). Grogan-Johnson et al.’s (2013) study had articulation
Even though effective treatments exist for CAS, and phonological disorders rather than CAS (S.
many families are unable to access speech pathologists Grogan-Johnson, personal communication, 6 February
to provide the required treatment, and when treatment 2015) and therefore these findings cannot necessarily be
is received it is often less frequent and for a shorter dura- applied to children with CAS. Effective treatments for
tion than necessary (Ruggero et al. 2012). These access CAS often focus on prosody or speech movements (Maas
difficulties are compounded for people who need to see et al. 2014, Murray et al. 2014) rather than targeting
a specialist clinician or who live in rural and remote areas specific sound errors in a step-by-step progression.
(O’Callaghan et al. 2005). Telehealth, with its provision There is currently no evidence for efficacy of video
of therapy services at a distance, can improve access conferencing for CAS treatments. The compromised
to both high-intensity speech-pathology treatments sound signal sometimes associated with video con-
(Mashima and Doarn 2008) and specialist clinicians. ferencing (Keck and Doarn 2014) may potentially
Telehealth delivery of ReST treatment 3
reduce the effectiveness of treatment. Given that speech 2007). We chose relatively low cut-off points for each
pathologists have an ethical responsibility to ensure their feature, as we were recruiting children up to 12 years
treatments are effective and efficient (Speech Pathology of age and the frequency and/or severity of behaviours
Australia n.d.), it is important to investigate the efficacy associated with the core perceptual features may possibly
of telehealth for delivering treatment for this population. reduce as children get older. Diagnosis of CAS was given
In this study we investigated the efficacy of ReST when (1) children < 11 years showed > 40% inconsis-
treatment for CAS via video conferencing, with the tency in word production on repeated attempts during
participants receiving treatment at home, using their the Inconsistency subtest of the Diagnostic Evaluation
own computers and existing Internet connection. of Articulation of Articulation and Phonology (DEAP;
The hypotheses were as follows: Dodd et al. 2006) or children aged ࣙ 11 years showed >
r ReST treatment, delivered four times a week for 30% inconsistency1 over three separate administrations
of 25 words from the Test of Polysyllables (Gozzard
3 weeks via video conferencing, will result in:
r acquisition of targeted speech behaviours, et al. 2006); (2) a minimum of 10 words exhibited
syllable segregation within words during the Test of
namely accurate production of phonemes, lex-
Polysyllables (Gozzard et al. 2006), indicating difficulty
ical stress pattern and smooth transitions be-
transitioning between syllables; and (3) a minimum
tween syllables, in imitated pseudo-words, as
of 15% stress pattern mismatches were produced on
perceived by the probe assessor;
r generalization of this treatment effect to un- the Test of Polysyllables, and the examiners perceived
abnormal prosody during conversational speech.
treated but related imitated speech behaviours:
r pseudo-words with the same phonemes and Two additional tests were used to provide more
detail on the severity of the children’s overall language
lexical stress patterns as treated items;
r real words with the same number of syllables and articulation skills relative to age-matched peers, but
were not used to determine suitability for the study: (1)
as the treated items.
r maintenance of speech gains up to 4 months the Clinical Evaluation of Language Fundamentals–
Preschool Second Edition (CELF-P2; Wiig et al.
post-treatment.
r Telehealth treatment will be viewed as compa- 2004) or the 4th Edition Australian version (CELF-4;
Semel et al. 2006), depending on age; and (2) the
rable or more desirable than intensive face-to-
Goldman–Fristoe Test of Articulation—2 (GFTA-2;
face clinic treatment, as measured via telephone
Goldman and Fristoe 2000).
interview with one caregiver per child, 4 weeks
The children were assigned pseudonyms. Their
post-treatment.
performance on the above speech and language tests is
reported in table 1.
Method All children had previously received speech therapy,
but did not have any other speech treatment from the
Participants
start of baseline testing until 1 month post-treatment.
Eleven monolingual Australian English-speaking chil- During the period between 1 and 4 months post-
dren consented to participate in the study. Six children treatment, none of the participants received speech-
were excluded from the study following assessment, as sound intervention; however, Emily received therapy
they did not meet the inclusion criteria defined below. to improve her receptive and expressive language skills.
Five children with a diagnosis of CAS aged 5:5 (years; The research project was approved by The University of
months) to 11:2 completed the study. Sydney Human Ethics Committee (reference number
Inclusion criteria were (1) consensus diagnosis of 2014/080).
CAS (see below), (2) passed pure tone audiometry at
20 dB at 500, 1, 2 and 4 kHz, (3) normal receptive
Design
vocabulary (Peabody Picture Vocabulary Test—4th
Edition; Dunn and Dunn 2007), and (4) normal oral A multiple baseline across participants design (Kazdin
structure (Oral and Speech Motor Protocol; Robbins 2011) was used in this study. Participants were
and Klee 1987). The diagnosis of CAS was made allocated either three, four, five or six twice-weekly
independently by the first two authors based on the baseline sessions. The treatment commenced after
perception of the presence of core perceptual features of different numbers of baseline sessions to demonstrate
CAS (American Speech–Language–Hearing Association that change occurred following the commencement of
2007) during a battery of speech production tests. There treatment, rather than after a certain number of baseline
are currently no specific tests or agreed cut-off points for sessions. During the treatment phase, each participant’s
determining the presence of the core perceptual features performance was monitored three times; immediately
(American Speech–Language–Hearing Association prior to treatment sessions five and nine, and 1 day
4 Donna C. Thomas et al.
Table 1. Participants’ initial assessment results

Oliver Jack Emily Luke Lachlan

(5 years; (11 years; (11 years; (5 years; (7 years;
Test 6 months) 0 months) 2 months) 3 months) 6 months)
Clinical Evaluation of Language Fundamentals—Preschool Second Edition (CELF-P2) or
Clinical Evaluation of Language Fundamentals—Fourth Edition (CELF 4)a
Receptive Language Index
Standard score 79 106 88 84 75
Percentile rank 8 66 21 14 5
Interpretation < NL mild WNL WNL < NL mild < NL moderate
Expressive Language Index
Standard score 92 112 63 59 70
Percentile rank 30 79 1 0.3 2
Interpretation WNL WNL < NL severe < NL severe < NL severe
Peabody Picture Vocabulary Test
Standard score 90 90 99 88 108
Percentile rank 25 25 47 21 70
Interpretation WNL WNL WNL WNL WNL
Goldman–Fristoe Test of Articulation
Standard score 79 45 75 58 69
Percentile rank 11 <1 <1 2 5
Interpretation < NL mild < NL severe < NL severe < NL severe < NL moderate
Test of Auditory Perception—Third Edition, Word Discrimination subtest
Scaled score 9 9 12 7 10
Percentile rank 37 37 75 16 50
Interpretation WNL WNL WNL WNL WNL
Inconsistency Assessmentb
% Inconsistency 68 32 44 64 48
Interpretation Inconsistent Inconsistent Inconsistent Inconsistent Inconsistent
Test of Polysyllables
% Consonants correct 76 84 85 36 67
% Vowels correct 67 91 88 50 74
% Phonemes correct 73 87 86 42 70
% Stress pattern errorsc 46 26 32 77 47
% Syllable segregationsd 20 20 25 21 22
Oral and motor speech protocol
Structure
Raw score 23 23 25 24 23
Interpretation WNL ˆ ˆ WNL ˆ
Function
Raw score 94 97 102 107 104
Interpretation < NL ˆ ˆ < NL ˆ
Observations Difficulty Reduced speaking Inconsistent Difficulty Difficulty imitating
coordinating lip volume, hypernasality. coordinating lip multisyllabic
and tongue intermittent Loud speaking and tongue words.
movements in hypernasality volume movements in Incoordination
non-speech and non-speech and during DDK
speech tasks speech tasks tasks
Notes: a Children aged 5 years completed the Clinical Evaluation of Language Fundamentals—Preschool Second Edition (CELF-P2), those aged more than 6 years completed the
Clinical Evaluation of Language Fundamentals—Fourth Edition (CELF 4); see the participants section for test references; WNL, within normal limits; NL, normal limits; DDK,
Diadochokinesis.
b
Children less than 11 years completed the Inconsistency subset of the Diagnostic Evaluation of Articulation and Phonology (Dodd et al. 2006) and those ࣙ 11 years completed three
productions of 25 words from the Test of Polysyllables (Gozzard et al. 2006). Inconsistent; see the participants section for further information regarding inconsistency assessment.
c
Calculated using Profile of Phonology (PROPH) software.
d
Percentage of words with at least one perceptually identified absence of smooth joining of the syllables; ˆ = outside of age range for normative scores.

post-treatment. Each participant’s performance was treatment effect across participants, with staggered
also monitored three times in the follow-up phase at 1 introduction of the independent variable across dif-
week, 4 weeks and 4 months post-treatment. ferent time points (Kazdin 2011). Although internal
Demonstration of experimental control in multiple- validity is typically addressed through replication of the
baseline designs is through the replication of the effect, research with children faces a threat to internal
Telehealth delivery of ReST treatment 5
validity as a result of maturation. As an additional
safeguard against maturation effects we included a
control behaviour to our probe stimuli for each child
(see ‘Probe stimuli’ for details).

Probe stimuli
A 90-item probe list was created for each child to permit
analysis of (1) treatment effect, (2) generalization to
related, but untreated items, (3) generalization to
real words with the same number of syllables as the
treated items, and (4) maturational control. The probe
stimuli included pseudo-word strings with strong–weak
(SW) stress patterns (e.g., /dabəfi/) and weak–strong
(WS) patterns (e.g., /kədɔfi/). The consonants for the Figure 1. Microphone and headphone set-up
pseudo-word stimuli represented different manner,
place and voicing conditions, namely /d/, /k/, /f/ and
Equipment
/b/. The vowels selected for the pseudo-word strings
were /a/, /ɔ/, /i/ and /ǝ/. The probe and treatment Video conferencing was conducted using Adobe
stimuli are included in appendix A. Connect, version 8, which had the function to share
Lachlan, Oliver, Jack and Emily’s probe list con- documents and interactive workspaces as well as
sisted of 20 SW and 20 WS three-syllable (CVCVCV) transmit real-time audio and visual information. The
pseudo-words, of which 20 (10 SW and 10 WS) were speech-pathology clinicians used either a Dell Latitude
treated and 20 (10 SW and 10 WS) remained untreated, E6320 laptop computer with an inbuilt web camera
in order to assess generalization to similar but untreated or a custom-built Bosch P8C WS desktop computer
items. The treated items were selected from the set of with Logitech C930e web camera. Clinicians wore a
pseudo-words, and each participant had a different set USB headset (Sennheiser PC 8 or Logitech H540). All
of treated items. The probe list also included 20 carrier participants used their home computer, with broadband
phrases (e.g., I found a ) with the three-syllable Internet connection. Participants wore a Sennheiser PC
strings to assess generalization effects to sentence level, 8 USB headset around the neck with the microphone
and 20 three-syllable real words to assess generaliza- positioned approximately 10 cm from the mouth to
tion to real words. Additionally, each child had 10 record sound and Yellowstone YSYROHRD head-
control items, which contained an articulation error phones over the ears (figure 1). A separate headphone
or phonological process that we hypothesized would and microphone for participants was used to enable
not change during ReST treatment, as it was unrelated a 3.5-mm audio splitter to connect to the caregiver’s
to treated items (e.g., a liquid when only plosives and Yellowstone YSYROHRD headphones allowing them
fricatives were trained, or an inter-dental lisp when to hear the child’s session. All sessions were recorded
prosody and nasality were targeted), or it represented through Adobe Connect for later assessment of
a more complex skill level than treated (e.g., clusters). treatment fidelity, scoring reliability, and for student
Lachlan’s control behaviour was production of word training purposes. The sessions were also recorded at
initial /s/ clusters, Oliver and Emily’s was articulation the participant’s home using an Olympus VN-711PC
of /r/ in initial and medial word position, and Jack’s was digital voice recorder; however, all data reported here
articulation of /s/ in initial- and final-word position. are based on the Adobe Connect recordings.
Luke’s speech difficulties were more severe than the The face-to-face initial assessments were audio
other participants and his treatment stimuli were two recorded with an AKG C520 headset microphone
syllable pseudo-words. His probe list contained 20 SW and Roland Quad Capture UA-55. They were video
and 20 WS two syllable (CVCV) pseudo-words, with recorded using a Bosch NBN-832V-P camera, and an
10 SW and 10 WS items randomly selected for treat- Electrovoice RE90HW microphone connected to a
ment, and 10 of each kept to assess generalization to un- Bosch DIVAR IP 7000 2U DVD.
treated items. His probe list also included 20 three sylla-
ble (CVCVCV) pseudo-words, to assess performance on
Procedure
more complex pseudo-words, 10 two syllable real words,
and 10 three syllable real words, to assess generalization The first author, a qualified speech pathologist, carried
to real words. Luke’s control behaviour was the produc- out the face-to-face eligibility assessments and video
tion of initial /l/ clusters (/pl/, /bl/, /kl/, /fl/ and /gl/). conferencing baseline probes. Jack and Oliver were
6 Donna C. Thomas et al.
treated by qualified speech pathologists experienced in Treatment
ReST treatment; while Lachlan, Luke and Emily were
The ReST treatment was used, following the procedure
treated by trained speech pathology students, under the
described in Murray et al. (2012). However, unlike
supervision of the first and second authors. The same
Murray et al. (2015), all children in this study imitated
clinician treated Emily and Lachlan. One clinician
the stimulus items, while looking at the written stimulus
treated each child for the duration of the treatment
rather than reading the items. Each session began with
phase.2
approximately 10 min of pre-practice to explain the task
and ensure the children had a reference of correctness for
Baseline and probe sessions the target stimuli. During pre-practice, the participants
(1) viewed a card with the written pseudo-word via
Identical procedures were used for baseline and the
the webcam, (2) listened and watched the computer
probe sessions. The probe list items were presented
monitor while the clinician produced the selected
in one of three randomized orders. The participants
written pseudo-word, from the 20 treatment items, and
viewed a PowerPoint slide show, with the orthogra-
(3) attempted to imitate the word production.
phy for each pseudo-word item and a picture plus
The participants were provided with knowledge
orthography for each real-word item and the sound
of performance (KP) feedback immediately following
file of an Australian English female speaker producing
each production (e.g., ‘That word was broken, the
each item. As the participant viewed each slide, the
parts were separated. Try to join the parts together
parent played the sound file for the item and the
smoothly’). A variety of cueing techniques were
child imitated the word. Imitation was used due to
employed such as breaking the words into syllables and
the non-familiarity of the pseudo-word items and to
rejoining, representing relative syllable duration with
ensure consistency of procedure between pseudo- and
magnetic strips on a whiteboard, slowing overall rate
real-word items. During the PowerPoint slide show, the
of production, and cueing about correct articulator
clinician could see and hear the participant via the web
placement. Once five items were produced correctly
camera and microphone, and the participant could hear
with modelling and shaping, the participant moved
the clinician, but see only the PowerPoint slide show.
into the practice phase. The pre-practice phase lasted
for up to 25 min in sessions 1, 2 and in any session
Technology set-up where a child progressed to a new level of treatment,
and approximately 10 min in all other sessions.
Prior to the baseline sessions, each participant had
In the practice phase, each participant aimed to
one or two 30-min web-conferencing familiarization
complete 100 trials ( x = 99, SD = 9.33): five trials
sessions where the treating clinician and child talked via
each of the 20 treated items, in random order. The
video conference, played interactive web-based games,
clinician provided a live model of the item for the child
and solved any technical difficulties with equipment or
to imitate during the practice trials. Knowledge of
connectivity.
results (KR) feedback (i.e., feedback about whether the
item was correct or incorrect) was provided on approx-
Technology rating imately 50% of the items after a delay of 3–5 s. After
every 20 trial items, a 2-min rest break was provided.
Following each session, the treating clinician completed
Once a participant achieved ࣙ 80% correct in
a form noting any technical issues, whether the issues
two consecutive practice sessions, the client began
were resolved and the strategies employed. The clinician
treatment on the next, more complex treatment level
also marked a line on a 10-cm visual analogue scale to
(see Murray et al. 2012 for levels in ReST treatment).
rate the technology in the session, from ‘very poor’ to
The progression criterion was met by Jack in session 5,
‘excellent’.
and Emily in session 10, and these children moved to
treatment on pseudo-words at the end of carrier phrases
Parent satisfaction (e.g., ‘She has a big /dəfabi/’ or ‘There’s a /dəbɔfi/’)
from sessions 6 and 11 respectively.
Four weeks post-treatment, telephone interviews were
conducted with the treating clinicians and the parents.
During the semi-structured interview, the parents
Dependent measures and data analysis
and clinicians used a 10-point rating scale (e.g., 0 =
not convenient at all, 10 = very convenient) to rate The probe assessors made perceptual judgments about
the convenience of the sessions, their perception of each probe item with regard to the accuracy of the
the child’s motivation and their overall satisfaction phonemes, stress pattern and fluency of syllable tran-
with the telehealth mode of treatment. sitions. Judgements were made about each construct
Telehealth delivery of ReST treatment 7
individually and, in order to be counted as correct, the Table 2. Reliability information
probe item needed (1) correct sounds, (2) correct lexical Probe itemsa
stress and (3) smooth connection of the syllables. The
dependent measure was the percentage of items correct Pseudo- Real Control Treatment
(i.e., with correct sounds, lexical stress and smooth words words sounds itemsa
connection between the syllables). The first author Judgements of correctness
conducted all baseline assessments. A rater blinded to Intra-rater 92 91.9 93.5 91
Inter-rater 89 87.3 81.5 88
the phase of treatment and baseline level of speech skill
conducted the probe assessments. Intra- and inter-rater Broad phonemic transcription
Inter-rater 89.4 82.5 92.8 95
reliability was calculated on 20% of each baseline Inter-rater 84.9 78.5 80.5 94
session, probe assessment and treatment session.
Note: a Percentage agreement.
Data for each participant were graphed for visual
analysis. Visual analysis consisted of examining the
level, trend, variability, overlap and immediacy of effect.
Visual analyses were supported with statistical analyses with later points (i.e., 1 and 4 months post-treatment
where possible. In order to do so, we tested each combined), and (3) 1 month post-treatment with 4
child’s data for independence by preliminary analyses months post-treatment. Effect sizes were calculated
of variance comparing phases, recording residuals from using the protocol described by Beeson and Robey
these analyses and testing the residuals for autocor- (2006): d2 = (mean score in follow-up phase – mean
relation. With the exception of Lachlan’s untreated score in baseline phase)/pooled standard deviation.
pseudo-words and carrier phrases, and Emily’s real
words, in all cases the lag 1 correlation of the residuals Reliability
was non-significant, indicating no evidence that the
assumption of independence was violated in most cases. Inter- and intra-rater reliability was calculated for
Where other analysis of variance (ANOVA) assumptions phonemic transcription and the scoring of articula-
were met, ANOVAs and Helmert planned orthogonal tion accuracy, stress pattern and fluency of syllable
contrasts were performed for each participant to test for transitions. Given the indications in the literature that
differences across phases (baseline, treatment, follow- perception of some sounds via video conferencing can
up) within behaviours (treated pseudo-words, untreated be unsatisfactory (see the Introduction for details),
pseudo-words, untreated real words, more complex reliability was calculated separately for pseudo-words
pseudo-words or pseudo-words in carrier phrases and items, real-word items and control items (table 2).
control words). In each case, the first Helmert contrast
compared the average within-participant performance Treatment fidelity
in the baseline phase with average performance over The first author examined a randomly selected
treatment and follow-up phases, and the second contrast 10 min of each session for treatment fidelity. Assess-
compared the average within-participant performance ment was made of the accuracy of the clinician’s model,
in the treatment phase with the follow-up phase. A the number of trials given feedback, the accuracy of the
study-wide adjustment to the significance level, to feedback, the type of feedback (i.e., KP in pre-practice
account for multiple comparisons, was not performed. and KR in practice), and the timing of feedback.
This is because the primary method of analysis was Average fidelity for treatment sessions was 95%
visual analysis, as is common in single-case design, with (SD = 6.1, range = 75–100). Fidelity was lowest in the
the statistical analyses used to confirm the results of first two sessions, involving clinicians giving feedback
visual analysis. Significance at both 0.05 and 0.01 levels without sufficient delay, and giving KP rather than KR
are indicated in table 3, and readers are advised to use feedback in the practice phase.
caution when interpreting significance values between
0.05 and 0.01. Where data were autocorrelated, only
visual analysis was performed. Results
In order to test for maintenance of treatment
Effects of treatment
effect within the follow-up phase, post-hoc planned
orthogonal contrasts were performed at the data points Oliver’s per cent accuracy with the to-be-treated items
within the follow-up phase, with the participants’ data during baseline was 0–10% (figure 2, panel A). His per
pooled. Contrasts were conducted of average perfor- cent accuracy steadily improved during the treatment
mance across participants at (1) 1 day post-treatment phase to 70%, and the difference between the baseline
with later points (i.e., 1 week, 1 month and 4 months phase and the later phases was significant. The results
post-treatment combined), (2) 1 week post-treatment of all significance testing can be found in table 3.
8 Donna C. Thomas et al.
Table 3. Planned contrasts and effect sizes

BL versus later
Effect size (i.e., T and FU combined) T versus FU

Word set d2= t= p= t= p= Change

∗∗
Oliver Treated pseudo-words 9.64 6.595 0.001 0.835 0.437 –
Treated pseudo-words in 2.04 2.418 0.065 5.156 0.68 –
phrases
Untreated pseudo-words 1.79 3.397 0.015∗ 1.343 0.229 –
Untreated real words 5.73 6.711 0.001∗∗ 0.731 0.497 –
Control /r/ articulation 1.63 1.277 0.251 0.583 0.583 –
Jack Treated pseudo-words 3.59 8.333 < 0.001∗∗ 0.177 0.111 –
Treated pseudo-words in 2.30 3.878 0.004∗∗ 0.282 0.784 –
phrases
Untreated pseudo-words 3.59 8.333 < 0.001∗∗ 0.176 0.111 –
Untreated real words 6.34 9.929 < 0.001∗∗ 1.136 0.286 –
Control /s/ articulation 0.00 1.065 0.316 1.523 0.168 –
Emily Treated pseudo-words 4.65 10.121 < 0.001∗∗ 2.705 0.003∗∗ ↓
Treated pseudo-words in 2.00 3.16 0.013∗ 0.321 0.757 –
phrases
Untreated pseudo-words 3.48 5.172 0.001∗∗ 4.84 0.525 –
Untreated real words
Control /r/ articulation 0.70 0.75 0.473 0.357 0.731 –
Luke Treated pseudo-words 21.24 16.588 < 0.001∗∗ 1.452 0.193 –
Untreated three-syllable 3.20 2.273 0.060 1.179 0.634 –
pseudo-words
Untreated pseudo-words 13.16 17.358 < 0.001∗∗ 0.515 0.275 –
Untreated real words 3.12 4.37 0.003∗∗ 1.029 0.341 –
Control /l/ clusters 0.64 5.952 0.001∗∗ 11.111 < 0.001∗∗ ↓
Lachlan Treated pseudo-words 6.79 3.791 0.009∗∗ 1.329 0.232 –
Treated pseudo-words in
phrases
Untreated pseudo-words
Untreated real words 3.87 4.6 0.004∗∗ 2.741 0.034∗ ↑
Control /s/ clusters 0.07 0.532 0.612 0.931 0.390 –
Note: Effect size = Cohen’s d2 using pooled standard deviations (Beeson and Robey 2006); BL, baseline phase; T, treatment phase; FU, follow-up phase; ∗∗ significant at 0.01; ∗ significant
at 0.05; –, No difference between treatment and maintenance phase; ↓, decrease in the follow-up phase; ↑, increase in the follow-up phase. Contrasts for Emily’s untreated real words
and Lachlan’s pseudo-words in phrases and untreated pseudo-words were not calculated because the data showed autocorrelation.

Jack’s per cent accuracy during the baseline phase Emily’s performance with the to-be-treated items
with the to-be-treated items ranged from 30% to 35% during the baseline phase ranged from 45% to 60% ac-
(figure 3, panel A). During the treatment phase, his curacy (figure 4, panel A). During the treatment phase,
per cent accuracy increased to 85–95%, resulting in her treated pseudo-word accuracy ranged from 84%
a significant difference between baseline performance to 90%, and planned contrasts confirmed Emily had
and later phase performance. Jack reached the a priori significantly better performance in later phases than in
criterion of 80% accuracy on treated behaviours over baseline. Emily reached the a priori criterion of 80% ac-
two consecutive treatment sessions in the fifth treatment curacy on treated single pseudo-words over two consecu-
session. His therapy target was therefore changed from tive treatment sessions in the 10th treatment session. Her
single pseudo-words to pseudo-words in carrier phrases treatment goal changed to the production of pseudo-
from session 6. During baseline, Jack’s per cent accuracy words in carrier phrases from session 11. Figure 4, panel
on treated pseudo-words in carrier phrases ranged B, shows that during baseline Emily’s per cent accuracy
between 0% and 10% (figure 3, panel B). In probe on treated pseudo-words in carrier phrases ranged be-
7, following the introduction of treatment on single tween 5% and 15%. Her accuracy with pseudo-words
pseudo-words, his performance on pseudo-words in in carrier phrases improved when she started treatment
carrier phrases improved to 90% accuracy, suggesting on single pseudo-words, suggesting generalization of
generalization of treatment effects (see below). His accu- treatment effects to more complex stimuli (see below).
racy with carrier phrases in probes 8 and 9 was similar to Luke’s per cent accuracy with the to-be-treated
probe 7. items during the baseline phase ranged from 5% to
Telehealth delivery of ReST treatment 9

Figure 2. Oliver’s results. PW, pseudo words; RW, real words.

10% (figure 5, panel A). During the treatment phase steadily improved to 75%, resulting in a significant
his accuracy with treated pseudo-words was 50–65% difference between the baseline phase and the later
and planned contrasts confirmed that the improvement phases.
from baseline to the later phases (treatment and
follow-up) was significant.
Lachlan’s per cent accuracy with the to-be-treated Generalization of treatment effects
items during baseline was 0–11% (figure 6, panel Oliver showed significant generalization to untreated
A). Within the treatment phase his per cent accuracy pseudo-words and untreated real words (figure 2,
10 Donna C. Thomas et al.

Figure 3. Jack’s results. PW, pseudo words; RW, real words.

panel C). During baseline, his per cent accuracy with improvement in these items during the treatment
untreated pseudo-words and untreated real words was phase, which was not statistically significant.
5–15% and 0–10% respectively. During the treatment Jack generalized his skill to similar, but untreated,
phase, his accuracy for these items improved signif- pseudo-words and untreated real words, as shown in
icantly to 16–55% and 30–45% respectively. Visual figure 3, panel C. In baseline, his accuracy was 60–70%
inspection of Oliver’s accuracy with pseudo-words in for untreated pseudo-words and 20–35% for untreated
carrier phrases (figure 2, panel B) indicates a small real words. During the treatment phase, his performance
Telehealth delivery of ReST treatment 11

Figure 4. Emily’s results. PW, pseudo words; RW, real words.

improved to 95% accuracy for untreated pseudo-words phrases increased from < 10% in probes 1–6 to 70%
and 60–75% for untreated real words. Planned in probe 7 following the introduction of treatment on
contrasts confirmed these differences were significant. single pseudo-words. Visual inspection indicated that
As treatment shifted to treated pseudo-words in carrier there was no difference between performance on treated
phrases after probe 7, Jack’s performance with treated pseudo-words in carrier phrases between probe session
words in carrier phrases in probe 7 was compared with 7 and later probe sessions, suggesting generalization to
his performance in the other baseline probes (figure 3, treated carrier phrases occurred once treatment began
panel B). Jack’s accuracy with pseudo-words in carrier on the pseudo-words (figure 3, panel B).
12 Donna C. Thomas et al.

Figure 5. Luke’s results. PW, pseudo words; RW, real words; syll., syllable.

Emily showed generalization to untreated pseudo- performance in the baseline phase and later phases was
words and untreated real words (figure 4, panel C). significant. As discussed previously, Emily also showed
During baseline, her per cent accuracy with untreated generalization to carrier phrases with pseudo-words
pseudo-words and untreated real words was 35–50% prior to treatment at the carrier phrase level. We
and 35–45% respectively. During the treatment phase, compared her accuracy with carrier phrases in probe 7
her accuracy for these items improved to 60–79% (the last probe prior to treatment on pseudo-words in
and 65–80% respectively, and the difference between phrases) to probes 1–5 (prior to treatment on single
Telehealth delivery of ReST treatment 13

Figure 6. Lachlan’s results. PW, pseudo words; RW, real words.

pseudo-words). In the first five probe sessions Emily Luke generalized his skills to similar, but untreated,
achieved < 10% accuracy on treated pseudo-words in pseudo-words and untreated real words, as shown in
carrier phrases. Her accuracy with this behaviour im- figure 5, panel C. During baseline, his accuracy with
proved steadily once treatment began on single pseudo- untreated pseudo-words and untreated real words was
words, resulting in 50% accuracy in probe 7. This 10–16% and 0% respectively. His accuracy improved
suggests generalization to carrier phrases with pseudo- on these untreated items during the treatment phase
words once treatment began on single pseudo-words resulting in accuracy levels of 50–60% for untreated
(figure 4, panel B). pseudo-words and 20–30% for untreated real words.
14 Donna C. Thomas et al.
Planned contrasts confirmed that these improvements treatment phase, even though all follow-up points had
were significant. Although visual inspection indicates higher accuracy than baseline levels. She did however
a small, temporary improvement with more complex maintain her treatment gain with treated pseudo-words
items (three-syllable pseudo-words; figure 5, panel B), in phrases. For these items, two follow-up points
the change in these items between the baseline phase had the same per cent accuracy as probe 7 (the final
and later phases (i.e., treatment and follow-up) was not probe prior to treatment on those items), and one
significant. had higher accuracy. Her performance was above
Lachlan showed significant generalization to baseline levels at all follow-up points for untreated
untreated pseudo-words and untreated real words pseudo-words, and untreated real words, and there
(figure 6, panel C). During baseline, his per cent was no significant difference between the treatment
accuracy with untreated pseudo-words and untreated and follow-up phase accuracy these items, indicating
real words was 10–20% and 5–15% respectively, both maintenance of generalization effects.
with slightly rising baselines. During the treatment In order to monitor the participants’ progress at
phase, his accuracy with these items improved to 20– different time points within the follow-up phase, the
40% and 20–30% respectively with the slope greater data for the four participants were grouped and Helmert
than predicted by the rising baseline. His untreated planned orthogonal contrasts were performed. There
pseudo-words showed autocorrelation of the residuals at was no significant difference between the participants’
lag 1 prohibiting statistical analyses. Planned contrasts performance at any of the time points, indicating stable,
indicated a significant difference between baseline rather than improving or deteriorating performance in
and later phase performance on untreated real words. the follow-up phase’.
Visual inspection indicates Lachlan did not show
generalization to pseudo-words in carrier phrases (figure
Control behaviour
6, panel B); statistical analysis was not conducted on
this data set due to autocorrelation of the residuals. Oliver, Jack and Emily did not show significant
change in the behaviours we selected to monitor for
maturational control (/r/, /s/, /r/ respectively) between
Maintenance of treatment and generalization effects
the baseline and later phases. Luke’s accuracy with
Most of the participants’ treatment and generalization the behaviour we selected to monitor to control for
gains were maintained for 4 months post-treatment. maturation effects (/l/ clusters), significantly improved
Oliver, Jack, Lachlan and Luke maintained all treatment during the treatment phase, and then significantly
and generalization effects throughout the follow-up pe- decreased in the follow-up phase. With regard to Lach-
riod. They had higher per cent accuracy at all follow-up lan, the behaviour we selected to monitor to control
points than baseline levels, for each of treated pseudo- for maturation effects (/s/ clusters), demonstrated a
words, similar but untreated words, and untreated ceiling effect (80–100% correct) in the baseline phase,
real words. Planned contrasts revealed no significant prohibiting adequate evaluation of change during the
difference between treatment phase and follow-up phase treatment phase. However Lachlan’s performance on a
accuracy for any of these items for Oliver, Jack and stimulus generalization measure (production of treated
Luke, supporting maintenance of effects to 4 months pseudo-words in carrier phrases) showed no significant
post-treatment. Lachlan had significantly higher change during the entire research period.
accuracy in the follow-up phase than the treatment
phase for untreated real words, indicating improving
Adequacy of technology
performance following the withdrawal of treatment.
Jack also maintained his skill with treated pseudo-words Although 61% of the sessions were rated by the treating
in phrases. His per cent accuracy at two of the follow-up clinician as having technology difficulties, only one of
points was at the same level as probe 7 (the final probe the 113 sessions (< 1%) was cancelled due to a technical
prior to treatment on carrier phrases), and at all follow- issue, namely the family had exceeded their service
up points was higher than baseline levels. No significant provider’s monthly data allowance. One additional
difference was found between his treatment phase session was conducted partly by telephone, due to issues
and follow-up phase performance on pseudo-words in with sound transmission during the video conference.
carrier phrases, supporting maintenance of skill. At the time of the final follow-up appointment, we
Emily maintained some of her treatment gains and assessed the speed of connection for all participants and
all of her generalization gains. With regard to mainte- clinicians. The download speed was above 50 Mbps for
nance of treatment gain, Emily lost some of her gain Jack, Emily and Lachlan, and below 4 Mbps for Oliver
with treated pseudo-words. She had significantly lower and Luke. Oliver and Luke had lower clinician ratings of
accuracy in the follow-up phase for these items than the technological adequacy than the other participants, with
Telehealth delivery of ReST treatment 15
average ratings of 5.45 and 6.73 out of 10 respectively, mance on a stimulus generalization task (production of
compared with an average rating for the other children pseudo-words in carrier phrases) was stable throughout
across all sessions of 8.40. The most frequent technical the research period. Although unrelated behaviours
difficulties experienced were difficulty establishing are usually selected to monitor for maturational
audio connection, web-camera freezing, and latency in change, an alternative way is to monitor for stimulus
the audio signal. At technology adequacy ratings of less generalization. Lachlan’s lack of change with a stimulus
than four (9% of sessions), clinicians reported feeling generalization task argues against maturational change,
frustrated, annoyed, stressed, and disappointed with and supports internal validity.
the technology. At technology adequacy rating levels Video conferencing ReST treatment had similar
above four (91% of sessions), clinicians reported feeling effects to face-to-face treatment (Ballard et al. 2010,
‘fine’, ‘comfortable’, ‘OK’ and ‘great’. Murray et al. 2015, Thomas et al. 2014). Both service
delivery methods resulted in significant acquisition
Satisfaction with video conferencing of pseudo-words, with large effect sizes. Significant
generalization to untreated but related behaviours, and
The parents were very satisfied with the video confer-
maintenance of treatment and generalization gains
encing treatment (average score = 9.5, range 7.5–10),
to 4 months post-treatment was shown in both the
and they reported their children were motivated to
face-to-face and telehealth modality.
participate in video conferencing sessions (average score
Two of the participants not only generalized to
= 8, range = 6.5–10) and they found the home-based
untreated items at the same level as treatment, but
treatment very convenient (average score = 9.7, range
also to more complex behaviours. Emily and Jack, who
= 8.5–10). The treating clinicians reported high levels
generalized to the more complex behaviour of pseudo-
of satisfaction (average score = 8.75, range 7.5–10) and
words in carrier phrases, had milder speech difficulties
convenience (average score = 9.25, range = 8.5–10)
initially than the other participants, were older, had
with the telehealth treatment.
accuracy levels above 80% during treatment and some
minimal knowledge of the more complex behaviour in
Discussion
baseline. Greater generalization in ReST treatment has
This study aimed to evaluate the efficacy of ReST been previously demonstrated for children with milder
treatment for children with CAS when provided by speech difficulties (Ballard et al. 2010, Thomas et al.
video conferencing. We hypothesized that treatment 2014) and ReST treatment is generally more effective
via video conferencing would result in (1) significant for older children with milder speech difficulties
improvement in imitated pseudo-words, (2) significant (Murray et al. 2013). Given that generalization to more
generalization to related but untreated imitated speech complex behaviours occurred prior to treatment at that
behaviours, and (3) maintenance of treatment and level, it raises the question of whether the children
generalization effects. The hypotheses were supported required treatment on the more complex behaviour.
with all five children showing positive gains, and four Further investigation of generalization to more complex
of the five children maintaining their gains to 4 months behaviours during ReST treatment is warranted.
post-treatment. With the exception of Emily’s accuracy with treated
Experimental control was indicated by the estab- pseudo-words, all children maintained their gains to
lishment of stable baselines prior to the introduction 4 months post-treatment. Emily’s loss of some treatment
of treatment, and the demonstration of improved gain with single pseudo-words is difficult to explain,
performance on the dependent variable when treatment particularly as she had high levels of treatment accuracy
commenced for all five children. Additionally, control and strong generalization. Perhaps she did not maintain
for maturation was demonstrated for all five children. sufficient focus on the single pseudo-words after her
Three children (Oliver, Jack and Emily) made no signif- treatment moved to phrases. Like the other participants,
icant change with the behaviour we selected as a matu- on all other behaviours, Emily had stable performance
rational control. For Luke, the behaviour we selected for in the follow-up phase. This stable performance in the
this purpose, (/l/ clusters), co-varied with the treatment. follow-up phase was also shown in face-to-face ReST
His return to baseline levels following the withdrawal treatment delivered twice weekly (Thomas et al. 2014),
of treatment argues against a maturation effect. For while face-to-face ReST treatment provided four times
Lachlan, the behaviour we selected to monitor for signs weekly resulted in significant ongoing improvement
of maturation (/s/ clusters), demonstrated a ceiling during the follow-up phase (Murray et al. 2015). This
effect in the baseline phase. Although a behaviour with present study was different to that of Murray and col-
lower levels of baseline performance would have ideally leagues in two significant ways: children with receptive
been selected, Lachlan did not have another speech language impairments were included and the mode of
behaviour appropriate for this purpose. His perfor- treatment was video conferencing rather than face to
16 Donna C. Thomas et al.
face. Either of these factors, or a combination of the Parents and clinicians found the system convenient,
two, may account for the superior performance in the motivating for the child, and were satisfied with their
maintenance phase for children receiving face-to-face experience of therapy via video conferencing. The high
treatment versus video conferencing treatment of the levels of satisfaction and convenience may be related
same intensity. to the interactive games played using Adobe Connect’s
Three of our participants had receptive language ‘draw’ function during session breaks and the reduction
impairments, and four had expressive language impair- in travel time with home-based video conferencing. This
ments. The treatment effect for children with language high satisfaction is in keeping with previous telehealth
impairments, particularly receptive impairments, studies (e.g., Constantinescu 2012). The children
may potentially be reduced. However, given that all attended all of their treatment and probe sessions. It
participants demonstrated significant acquisition of the is possible that the benefits in terms of convenience
targeted pseudo-words and generalization effects, any helped outweigh technical difficulties experienced.
limitation associated with the inclusion of participants The reliability of phonemic transcription was similar
with language impairments is minimal. in this study to face-to-face ReST treatment (cf. Thomas
The stable performance during maintenance in et al. 2014). Based on previous research indicating dif-
this study was a positive finding, given the relatively ficulty perceiving high frequency sounds, clusters, and
low levels of treatment accuracy shown by Lachlan, phonemes without visible articulation (Eriks-Brophy
Luke and Oliver. Previous studies with ReST and other et al. 2008, Waite et al. 2006) we would not have
motor speech disorders have indicated that high levels been surprised to find poor reliability for the control
of treatment accuracy, around 70%, for approximately items (/s/, /l/ clusters, /s/ clusters, and /r/), however the
five treatment sessions are generally required for average intra- and inter-rater reliability for the control
maintenance of treatment gains (Ballard et al. 2010, items was acceptable at 93.5% and 81.5% respectively.
Wambaugh et al. 2013). ReST treatment, with its use
of motor learning principles to facilitate generalization
Limitations and future directions
and maintenance, has previously demonstrated mainte-
nance of treatment gains, even with treatment accuracy This was a small, phase 1 study. It would be beneficial
levels below 70% (Staples et al. 2008, Thomas et al. to investigate the use of video conferencing for ReST
2014). These findings suggest that clinicians may be treatment in a larger group study, and to investigate
able to use a lower criterion for treatment accuracy than the factors affecting treatment outcomes for children.
is currently recommended for ReST treatment. It would also be beneficial to know if the results would
With regard to the technology used in the sessions, be replicated within a community clinical setting, as
although the majority of the sessions had some technical our study was conducted within a university treatment
difficulty, fewer than 1% of sessions were cancelled, research clinic.
indicating that the technical issues were tolerable for Related to design, we had three to six data points
the families. Audio latency was the most troubling in the baseline phase, and three in the treatment and
technical issues because it affected the interaction follow-up phases. More data points in each phase, with a
between clinician and client, as well as the ability to minimum of five in the treatment phase would be prefer-
provide timely feedback and no solution was available able. We demonstrated control for maturational effects
for sessions with audio latency. Although most of the on the selected behaviour for four of the five partici-
other technical issues could be resolved, in some cases pants. We only demonstrated control for maturational
problem solving took up to 10 min, which was more effects for Lachlan on a stimulus control behaviour.
than 15% of the session. Parents reported that the two Further studies should explore options for behaviours
familiarization sessions were valuable for improving appropriate to monitor for maturational change, and
their technical skill and confidence. The time required explore stimulus generalization tasks and more complex
for solving technical problems and familiarizing families behaviours as control measures for this purpose.
with video conferencing systems needs to be factored In this study, two participants demonstrated
in when considering using telehealth treatments. generalization to more complex speech behaviours.
Despite the technical challenges, ReST treatment Further investigation of the factors associated with
was efficacious in this format. It may be that the nature generalization in ReST treatment is required, and more
of a high-production trial treatment with minimal need data collection points within each phase may clarify
for physical prompts such as ReST is well suited to the results. The participants in this study imitated
video conferencing. CAS treatments requiring more the treatment and probe items, which may lead to
hands-on cueing such as Dynamic Temporal and limited generalization to spontaneous speech. Further
Tactile Cueing (DTTC) (Strand et al. 2006) may be investigation of the spontaneous speech production
less suitable for video conferencing. following ReST treatment is warranted.
Telehealth delivery of ReST treatment 17
The dependent variable in this study was the per- References
centage of words produced with correct sounds, lexical AMERICAN SPEECH–LANGUAGE–HEARING ASSOCIATION, 2007,
stress and smooth connection between the syllables. Childhood Apraxia of Speech. Technical Report (avail-
It would be beneficial to investigate the change within able at: http://www.asha.org/policy/PS2007-00277.htm) (ac-
each construct, within participant, over the course cessed on 22 of August 2015).
of treatment in order to provide information about BALLARD, K. J., ROBIN, D. A., MCCABE, P. and MCDONALD, J.,
2010, A treatment for dysprosody in childhood apraxia of
precisely what changes for each child, when the change speech. Journal of Speech Language and Hearing Research, 53,
occurs, and any pattern of change. The participants in 1227–1245.
this study used headphones, which would have atten- BEESON, P. M. and ROBEY, R. R., 2006, Evaluating single-subject
uated their auditory feedback from their own speech. treatment research: lessons learned from the aphasia literature.
This may have potentially reduced the treatment effect, Neuropsychology Review, 16, 161–169.
CAREY, B., O’BRIAN, S., LOWE, R. and ONSLOW, M., 2014, Webcam
but given the large treatment effects demonstrated may delivery of the Camperdown Program for adolescents who
not be of significance on this occasion. Finally, future stutter: a phase II trial. Language, Speech, and Hearing Services
speech treatment studies using video conferencing in Schools, 45, 314–324.
should include routine testing of the bandwidth at the CICCIA, A. H., WHITFORD, B., KRUMM, M. and MCNEAL, K., 2011,
start of each session in order to provide information Improving the access of young urban children to speech,
language and hearing screening via telehealth. Journal of
about the minimum bandwidth for effective treatment. Telemedicine and Telecare, 17, 240–244.
CONSTANTINESCU, G., 2012, Satisfaction with telemedicine for
teaching listening and spoken language to children with
Conclusions hearing loss. Journal of Telemedicine and Telecare, 18, 267–
This study evaluated the efficacy of ReST treatment 272.
CONSTANTINESCU, G., THEODOROS, D., RUSSELL, T., WARD, E.,
provided by telehealth to five children with CAS. WILSON, S. and WOOTTON, R., 2011, Treating disordered
Results showed significant acquisition of the imitated speech and voice in Parkinson’s disease online: a random-
targeted pseudo-words, and generalization of the ized controlled non-inferiority trial. International Journal of
treatment effect to untreated imitated pseudo-words Language and Communication Disorders, 46, 1–16.
and real words. These results suggest that video DODD, B., ZHU, H., CROSBIE, S., HOLM, A. and OZANNE, A., 2006,
Diagnostic Evaluation of Articulation and Phonology (DEAP)
conferencing as a service delivery method for ReST (London: Psychology Corporation).
treatment may be beneficial for children with CAS. DUNN, L. M. and DUNN, D. M., 2007, Peabody Picture Vocabulary
These results warrant larger scale studies. Test (PPVT-4) (Minneapolis, MN: Pearson Assessments).
ERIKS-BROPHY, A., QUITTENBAUM, J., ANDERSON, D. and NELSON,
T., 2008, Part of the problem or part of the solution? Com-
Acknowledgments munication assessments of Aboriginal children residing in
remote communities using video conferencing. Clinical Lin-
The authors extend their thanks to the families and children who guistics and Phonetics, 22, 589–609.
participated. They also thank the treating clinicians, probe assessors, GOLDMAN, R. and FRISTOE, M., 2000, Goldman–Fristoe Test of Ar-
interviewer and interns: Loren Apokourastos, Joanna Breinl, Kate ticulation 2 (GFTA-2) (Minneapolis, MN: Pearson Assess-
Broome, Lorayne Bejani, Caitlin Chaney, Ashleigh Hillyer, Monique ments).
Hines, Michelle Huynh, Kate Kirkton, Emily Lim, Natalie Lloyd, GOZZARD, H., BAKER, E. and MCCABE, P., 2006, Children’s pro-
Rebecca Medwin, Lauren Reed and Jessica Thambyaiyah. They also ductions of polysyllables. ACQuiring Knowledge in Speech,
thank Rob Heard for his advice on statistical analysis, and Sonya Language and Hearing, 8, 113–116.
Corcoran for her advice about Adobe Connect. This research was GROGAN-JOHNSON, S., SCHMIDT, A. M., SCHENKER, J., ALVARES, R.,
partially funded through the following sources: an Australian Post ROWAN, L. E. and TAYLOR, J., 2013, A comparison of speech
Graduate Award and Postgraduate Research Support Scheme fund- sound intervention delivered by telepractice and side-by-side
ing to Donna Thomas; and the Australian Research Council Future service delivery models. Communication Disorders Quarterly,
Fellowship (FT 120100355) to Kirrie Ballard. The researchers are 34, 210–220.
aware of no conflicts of interest. HILL, A. J., THEODOROS, D. G., RUSSELL, T. G., CAHILL, L. M.,
WARD, E. C. and CLARK, K. M., 2006, An Internet-based
telerehabilitation system for the assessment of motor speech
Notes disorders: a pilot study. American Journal of Speech–Language
1. For children ࣙ 11 years, the stimuli of the DEAP (Dodd Pathology, 15, 45–56.
et al. 2006) were not considered sufficiently challenging to as- KAZDIN, A. E., 2011, Single-Case Research Designs: Methods for Clini-
sess inconsistency. For these children an inconsistency measure cal and Applied Settings (New York: Oxford University Press).
was calculated for 25 words from the Polysyllabic Word Test KECK, C. S. and DOARN, C. R., 2014, Telehealth technology ap-
(Gozzard et al. 2006). As there are no guidelines for the severity plications in speech–language pathology. Telemedicine and e-
of inconsistency with these stimuli, we assumed children of 11 Health, 20, 653–659.
years would show < 30% inconsistency. For children < 11 years LEWIS, B. A., FREEBAIRN, L. A., HANSEN, A. J., IYENGAR, S. K. and
we used the 40% criteria for inconsistency, as reported by Dodd TAYLOR, H. G., 2004, School-age follow-up of children with
et al. (2006). childhood apraxia of speech. Language, Speech, and Hearing
2. Due to logistical constraints, the first author, experienced in ReST Services in Schools, 35, 122.
treatment via telehealth, conducted one treatment session of both MAAS, E., GILDERSLEEVE-NEUMANN, C., JAKIELSKI, K. and
Jack and Emily’s 12 treatment sessions. STOECKEL, R., 2014, Motor-based intervention protocols in
18 Donna C. Thomas et al.
treatment of childhood apraxia of speech (CAS). Current De- SKINDER-MEREDITH, A., 2001, Differential diagnosis: Developmen-
velopmental Disorders Reports, 1, 197–206. tal apraxia of speech and phonologic delay. Augmentative
MASHIMA, P. A. and DOARN, C. R., 2008, Overview of telehealth Communication News, 14, 5–8.
activities in speech–language pathology. Telemedicine and e- SPEECH PATHOLOGY AUSTRALIA, n.d., Code of Ethics (available at:
Health, 14, 1101–1117. http://www.speechpathologyaustralia.org.au/library/Ethics/
MURRAY, E., MCCABE, P. and BALLARD, K. J., 2012, A comparison of CodeofEthics.pdf\051 (accessed on 9 February 2015).
two treatments for childhood apraxia of speech: methods and STAPLES, T., MCCABE, P., BALLARD, K. J. and ROBIN, D. A., 2008,
treatment protocol for a parallel group randomised control Childhood apraxia of speech: treatment outcomes at 6 months
trial. BMC Pediatrics, 12, 122. of an intervention incorporating principles of motor learning.
MURRAY, E., MCCABE, P. and BALLARD, K. J., 2013, Exploring fac- Paper presented at the Joint New Zealand Speech–Language
tors that determined treatment success: data from a randomized Therapy Association/Speech Pathology Australia Conference,
control trial for childhood apraxia of speech. Paper presented at Auckland, New Zealand.
the ASHA Convention. Chicago, IL, USA. STRAND, E. A., STOECKEL, R. and BAAS, B., 2006, Treatment
MURRAY, E., MCCABE, P. and BALLARD, K. J., 2014, A system- of severe childhood apraxia of speech: a treatment efficacy
atic review of treatment outcomes for children with child- study. Journal of Medical Speech–Language Pathology, 14, 297–
hood apraxia of speech. American Journal of Speech–Language 307.
Pathology, 23, 486–504. THEODOROS, D., 2011, Telepractice in speech–language pathology:
MURRAY, E., MCCABE, P. and BALLARD, K. J., 2015, A random- the evidence, the challenges, and the future. Perspectives on
ized control trial for children with childhood apraxia of Telepractice, 1, 10–21.
speech comparing rapid syllable transition treatment and the THEODOROS, D., 2013, Speech–language pathology and telerehabil-
Nuffield Dyspraxia Programme—Third Edition. Journal of itation. In S. Kumar and E. R. Cohn (eds), Telerehabilitation
Speech, Language and Hearing Research, 58, 669–686. (London: Springer), 311–323.
NAMASIVAYAM, A. K., PUKONEN, M., GOSHULAK, D., HARD, J., THOMAS, D. C., MCCABE, P. and BALLARD, K. J., 2014, Rapid Syl-
RUDZICZ, F., RIETVELD, T., MAASSEN, B., KROLL, R. and lable Transitions (ReST) treatment for childhood apraxia of
LIESHOUT, P., 2015, Treatment intensity and childhood speech: the effect of lower dose-frequency. Journal of Com-
apraxia of speech. International Journal of Language and munication Disorders, 51, 29–42.
Communication Disorders, 50, 529–546. doi: 10.1111/1460- WAITE, M. C., CAHILL, L. M., THEODOROS, D. G., BUSUTTIN, S.
6984.12154 and RUSSELL, T. G., 2006, A pilot study of online assessment
O’BRIAN, S., SMITH, K. and ONSLOW, M., 2014, Webcam delivery of of childhood speech disorders. Journal of Telemedicine and
the Lidcombe Program for early stuttering: a phase I clinical Telecare, 12, 92–94.
trial. Journal of Speech, Language, and Hearing Research, 57, WAITE, M. C., THEODOROS, D. G., RUSSELL, T. G. and CAHILL,
825–830. L. M., 2012, Assessing children’s speech intelligibility and
O’CALLAGHAN, A. M., MCALLISTER, L. and WILSON, L., 2005, Bar- oral structures, and functions via an Internet-based telehealth
riers to accessing rural paediatric speech pathology services: system. Journal of Telemedicine and Telecare, 18, 198–203.
health care consumers’ perspectives. Australian Journal of Ru- WAMBAUGH, J. L., NESSLER, C., CAMERON, R. and MAUSZYCKI, S. C.,
ral Health, 13, 162–171. 2013, Treatment for acquired apraxia of speech: examination
REYNOLDS, A. L., VICK, J. L. and HAAK, N. J., 2009, Telehealth of treatment intensity and practice schedule. American Journal
applications in speech–language pathology: a modified nar- of Speech–Language Pathology, 22, 84–102.
rative review. Journal of Telemedicine and Telecare, 15, 310– WIIG, E. H., SECORD, W. and SEMEL, E. M., 2004, CELF Preschool
316. 2: Clinical Evaluation of Language Fundamentals Preschool—
ROBBINS, J. and KLEE, T., 1987, Clinical assessment of oropharyngeal Second Edition Australian Standardised Edition (Sydney, NSW:
motor development in young children. Journal of Speech and Harcourt Assessment).
Hearing Disorders, 52, 271–277.
RUGGERO, L., MCCABE, P., BALLARD, K. J. and MUNRO, N., 2012,
Paediatric speech–language pathology service delivery: an ex- Supporting Information
ploratory survey of Australian parents. International Journal
of Speech–Language Pathology, 14, 338–350. Additional Supporting Information may be found in the
SEMEL, E., WIIG, E. and SECORD, W., 2006, Clinical Evaluation of online version of this article at the publisher’s website:
Language Fundamentals Fourth Edition, Australian Standard-
ised Edition (CELF-4 Australian) (Sydney, NSW: Pearson). Appendix 1 Probe stimuli for the children