Enhancing Clinical Impact of Telepractice: Applications from Learning Science
There is a major concern among clinicians working with children who exhibit cognitive and communication issues that the current educational and therapeutic restrictions related to the COVID-19 pandemic may decrease in therapeutic outcomes. Last month, in this newsletter, Lesley Sylvan (2020) discussed the anticipated impact noting, “There is broad agreement that the most vulnerable populations of students (e.g., students with disabilities, English language learners, students from historically disadvantaged racial and cultural backgrounds) will be most negatively impacted.” The American Speech-Language Hearing Association (ASHA) has provided telepractice guidelines to ensure the continued quality and use of evidence-based intervention approaches (ASHAWire, 2020). But concerns persist, especially among school and hospital-based SLPs, because telepractice so alters conventional therapeutic methodology.
Recently, Dr. Stanislas Dehaene, an educational neuroscientist, has reviewed scientific research on brain changes associated with learning combined with insights gained from artificial intelligence technology in his new book, How We Learn: Why Brains Learn Better than Any Machine...For Now (2020). The focus is to better understand effective instructional methodologies that drive human brain learning capacities. Much of the research is applicable to therapeutic intervention as well as direct instruction, irrespective of the learning environment.
Although he covers many areas of neuroscience research, four of the brain-driven learning principles Dehaene emphasizes are especially applicable to telepractice as well as in person intervention. But, since many school districts are currently also using online educational programs to supplement direct instruction, the research-based guidelines may be especially useful to school and hospital-based SLP’s doing remote therapy. They are applicable as well to selection of technological resources that may be used to augment therapeutic dose when telepractice intervention time or access is limited.
Attention as a gateway to learning. SLP’s recognize that attention is the gateway to learning. As discussed in my forthcoming book from Plural Publishing, Cognitive and Communication Interventions: Neuroscience Applications for Speech-Language Pathologists, neuroscientists have confirmed this over several decades with research on effects of attentional neuromodulators on learning and retention. Nothing new can be learned or acquired if a client is attending to something other than the content or task at hand. So, prior to each telepractice session, family members can help by eliminating potential sources of distraction. When deemed clinically appropriate, parents or other family members may also be present during the sessions to draw attention to new important information. The clinician can also continually encourage comments, open discussion, and/or responses to maintain focus.
When working with clients who struggle with more generalized attentional difficulties, research indicates online technological activities and exercises designed by neuroscientists to enhance attentional focus and improve sustained attention may be added to supplement direct treatment sessions. BrainFutures, an independent national initiative has published a list of neuroscience evidence-based therapeutic options, several of which have been shown to enhance attention in individuals with attentional disorders.
Student engagement is critical. Dehaene (2020) emphasizes the importance of keeping clients actively engaged in the learning process. He states that passive students have trouble learning. To increase a student’s engagement in learning he suggests encouraging curiosity and asking the student to generate their own hypotheses. For example, frequently asking the student “Why” questions such as “Why do you think this is important?” Client engagement is also increased when treatment material is adapted to target what Vygotsky termed the “zone of proximal development,” maintaining tasks accuracy at an 80% level of correct responses with 20% of the items posing a challenge (Goswami, 2008).
Miller and Rollnick (2012) provide a useful Dynamic Coaching model applicable to remote telepractice to use with older clients to increase engagement in goal setting. The model includes five coaching components that begin with understanding the client’s perspective with empathy, moving to exploration of discrepancies between current behaviors and life goals, leading to mutual problem-solving of solutions.
Reward progress. Reward circuits are known to drive constructive changes in the human brain essential for learning (Sapolsky, 2017). Clinicians should consistently reward a client’s effort, not just achievement. Dehaene (2020) also clarifies how children and adolescents’ social brains respond to smiles and words of encouragement. In that regard, a client’s own awareness of their specific progress is also a powerful reward. Telepractice sessions should also be organized to provide immediate corrective feedback on error responses.
Encourage effort and productive struggle. Dr. Dehaene (2020) also emphasizes that successful therapeutic outcomes cannot be effortless. He states that, for all of us, interesting learning experiences, whether therapeutic in nature or involving skill sets in reading, math, science, athletics, or playing an instrument, require consistent and purposeful practice over extended periods of time. The belief that interventions should not be “too hard,” discourages effort and persistence. Clinicians can provide iconic examples, based on a client’s personal heroes, that exemplify the effort required to master the skill they are known for, whether famous athletes, artists, public speakers, actors, or scholars, then translate that to therapeutic goals.
Productive struggle is a term used widely in athletic training and mathematics but is now being applied more broadly to all areas of learning (Sriram, 2020). It refers to providing opportunities for clinically relevant robust application to real world settings as well as rigorous practice outside the clinic. For example, if a client is working on storytelling, during telepractice sessions the clinician and client can identify specific activities with clear therapeutic objectives (e.g., tonight I will tell my parents a story about my favorite baseball player, a very important game I watched, and why I think that player helped the team to win). By practicing the task during the clinical session, then continuing to practice with family members at specified times like dinner or before bed and again perhaps the next day, the value of productive struggle is reinforced and outcomes enhanced.
In summary, neuroscience and learning science have provided research on methodologies that maximize human brain learning. These methods can be applied to increase the impact and outcomes of telepractice as well as in-person clinical interventions.
American Speech Language Hearing Association. (2020). ASHAWire: Telepractice and computer based approaches. Retrieved from https://leader.pubs.asha.org/topic/asha-topics/teleprac
Brain Futures. (2020). Translating science to advance human potential. Retrieved from https://www.brainfutures.org/?sumo_email_id=58e8a3a0-110e-41b4-8f33-337d0d4c934d&utm_campaign=sumo-email
Burns, M. (2021). Cognitive and communication interventions: Neuroscience applications for speech-language pathologists. Plural Publishing.
Dehaene, S. (2020). How we learn: Why brains learn better than any machine... for now. Penguin.
Goswami, U. (2008). Principles of learning, implications for teaching: A cognitive neuroscience perspective. Journal of Philosophy of Education, 42(3–4), 381–399.
Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change. Guilford Press.
Sapolsky, R. M. (2017). Behave: The biology of humans at our best and worst. Penguin.
Sriram, R. (2020) The neuroscience behind productive struggle. Edutopia, April 14. Retrieved from https://www.edutopia.org/article/neuroscience-behind-productive-struggle
Sylvan, L. (2020) Tackling the current challenges faced in public schools: MTSS as part of the solution. Retrieved from