SEASON 7 EPISODE 5

[INTRODUCTION]

[0:00:14] ANNOUNCER: Welcome to SLP Learning Series, a podcast series presented by 
SpeechTherapyPD.com. The SLP Learning Series explores various topics of speech-language 
pathology. Each season dives deeper into a topic with a different host and guests, who are 
leaders in the field. Some topics include stuttering, AAC, sports concussion, teletherapy, ethics 
and more. Each episode has an accompanying audio course on SpeechTherapyPD.com and is 
available for 0.1 ASHA CEUs. Now, come along with us as we look closer into the many topics 
of speech-language pathology.

[0:01:05] ANNOUNCER: Welcome to Season 7. Telepractice: It's Not Just Screen Time.

[INTERVIEW]

[0:01:14] KHK: All right, so welcome to the podcast mini-series, Telepractice: It's Not Just 
Screen Time, presented by SpeechTherapyPD.com. Thanks for joining us for our fifth episode, 
Empowering Parents Via Teletherapy: Early Intervention to School-Age Children. This audio 
course is offered for 0.1 ASHA CEUs. I am your host, Karin Hartunian Koukeyan. I've been a 
speech-language pathologist for over two decades and working in telepractice for the past 12 
years, serving in both special education and healthcare.

Before we get started, we have a few items to mention. We love and encourage questions from 
our participants. You can put your questions in the chat box for our guest will answer them 
towards the end of the episode. As a reminder, if your state license requires CEUs, be sure to 
complete all course modules, including the one that says "Quiz" before the end of today on your 
SpeechTherapyPD.com account.

Here are the financial and non-financial disclosures. Karin Hartunian Koukeyan is the host of 
this podcast and receives compensation from SpeechTherapyPD.com, and she is also currently 
the Clinical Program Director at SLP Tele. Her non-financial disclosures are that she is the 
current SIG 18 associate coordinator for ASHA. Megan Ramirez was paid an honorarium for 
this presentation. She is the owner of Little Fish Speech Therapy LLC. Her non-financial 
disclosures are that she is a member of SIG 18 for telepractice.

Now, here's a little bit about our guest today. Megan Ramirez is a bilingual speech pathologist 
who specializes in working with autistic children and the early intervention population via 
teletherapy. She received her bachelor's degree from the University of Delaware in Spanish 
literature and linguistics in 2011. Megan went on to receive her master's degree in speech and 
language pathology from Syracuse University in 2014. Megan spent the first part of her career 
working in the outpatient setting at a children's hospital where she treated children with a variety 
of medical diagnoses.

She then transitioned to volunteer as a speech pathologist in the underprivileged communities 
of Trujillo, Peru, where she worked to treat medically fragile children. While in Peru, Megan also 
worked to provide education to local therapists. After her year-long contract in Peru ended, 
Megan began working as a speech pathologist via teletherapy, specializing in coaching parents 
of autistic children and children ages two to five. In 2021, Megan opened a private practice 
which specializes in providing neurodiversity affirming speech therapy services. Welcome, 
Megan.

In this episode, we will be covering the following learner outcomes. By the end of the course, 
participants will be able to define parent coaching via teletherapy, summarize research 
supporting parent coaching via teletherapy, define speech and language outcomes for parent 
coaching intervention via teletherapy with the early intervention preschool and autistic 
population. Let's get started with a question about you. We would love to hear about how you 
began your journey as a SLP and then came upon telepractice.

[0:04:52] MR: Sure. I was working as an SLP in Peru. When I finished my contract in 2018, I 
began looking for online work. I actually started working with an online dictionary doing 
translations for them. Then, I actually came across SLP tele where I met Corinne. That's when I 
began working in teletherapy, and that was in 2019. I continue to do teletherapy, because I love 
the teletherapy platform. I loved seeing the progress. It was just a really great experience 
overall. Then in 2021, I opened up my teletherapy practice.

[0:04:52] KHK: Amazing. Love it. What type of clients do you see in your private practice and 
where are they located?

[0:05:41] MR: I see a wide range of clients. A lot of them are from two to probably around 
young adults. I work with autistic children, the early intervention and preschool population. I 
work with kids who are working on articulation therapy. I work with a lot of Gestalt language 
processors. So those kiddos who communicate using echolalia, we work to help them create 
novel natural language, and my kids are all over. They are mainly in New Jersey and 
Washington. But I do have a few in other states, such as California and North Carolina as well.

[0:06:22] KHK: Excellent. Let's go ahead and get started with our main topic of interest today; 
parent coaching. What is parent coaching and how does it work? And while you're discussing 
that, also define for us what is not considered parent coaching?

[0:06:39] MR: Great. When we speak about parent coaching, this can mean coaching a 
guardian, sibling, grandparent, really whoever is regularly attending those speech sessions with 
the client. Parent coaching involves educating parents on the use of the strategies or 
interventions, as well as allowing them to practice the intervention with their child at the 
supervision of the SLP. It includes a lot of elements, sharing knowledge from the SLP, to the 
parent, or the caregiver, the SLP demonstrating the strategy. For example, explaining and 
demonstrating how to use modeling in order to increase a child's single word utterances, for 
example.

The SLP, observing the parent with the child, as the parent practices the strategy or the 
intervention, and then the SLP providing feedback. It also includes parent reflection on the use 
of the intervention, and discussing problem solving with the SLP. It is really important to have all 
those elements together. In the literature, there is actually not one single definition of parent 
coaching. We'll see a lot out there. But in general, we do see that these collaborative elements 
between the SLP and the caregiver is what is consistent in the literature.

What we don't consider to be parent coaching is just a conversation with the SLP and the 
parent. While that might be an important component of it, a conversation and sharing knowledge 
in isolation by itself isn't parent coaching. We also don't consider it to be parent observation of 
the SLP. Also, while that is an important component, alone, it's not considered to be parent 
coaching. We really need to have all of these collaborative elements of sharing knowledge, 
demonstrating a strategy, seeing the parent, then interacting with the child and providing the 
feedback in order for it to be considered parent coaching.

[0:08:36] KHK: That's very interesting. I see the parent observing the therapist as being more 
passive. Whereas, the sharing of knowledge and demonstrating a strategy is being more 
interactive and more of an active learning experience. I'd love to hear a little bit more about how 
technology is used in telepractice to do the sharing of knowledge and demonstrate strategies. 
The more detail you could give us, I know our audience would really appreciate that.

[0:09:05] MR: Sure. I think it depends on the platform. But when we talk about sharing 
knowledge, I think it's a matter of having not just one, but multiple conversations with the parent 
about our intervention, and why we're doing what we're doing in terms of the intervention. 
Because if the parent doesn't quite understand the reasoning behind it, then it's not going to be 
nearly as effective. I think, via teletherapy, having many conversations with the parent about our 
intentions, about what we're trying to achieve, what our goals are, that's the first step.

Then when it comes to modeling the actual intervention ourselves as the clinicians, that can 
look very different depending on the child's goals, and depending on the dynamic. Sometimes 
that might include sharing a screen for example, or maybe we're working on articulation words 
with Tic-Tac-Toe. So I just share my screen and I might demonstrate the intervention, and I'm 
playing Tic-Tac-Toe with the kiddo while we're doing our therapy, and then the parent is doing it. 

Sometimes it involves the parent participating in an activity with the child as I'm providing some 
feedback. I really think, yeah, depending on the child and their needs, and the parent, and the 
goals really depends on those different factors. It can definitely vary.

[0:10:27] KHK: Do you have any examples of good reflection questions that you might use with 
parents?

[0:10:34] MR: I might ask them how they thought that the intervention or their implementation of 
the intervention went. I think when parents sometimes, they might even initiate that conversation 
after an activity, and they might ask questions. That's how I really know that they are actively 
learning, and actively participating in these interventions. When they start to ask questions is 
kind of when the light bulb goes on, because that's when I know the wheels are really turning for 
them. I like to just kind of have those open-ended questions for them. ÒHow did you feel that it 
went, or what do you think now knowing what you know, what do you think that you might do 
differently next time?Ó That way, we are kind of actively guiding them towards working with that 
particular intervention with their child.

[0:11:31] KHK: Definitely. I'm curious, I've always thought it was challenging that, in 
telepractice, we can't share the same object. How do you do modeling for the parents through 
telepractice?

[0:11:46] MR: Sometimes, roleplay actually might be the most effective. For example, if we 
have a kiddo who is really active, and maybe they are one of those kiddos that maybe doesn't 
attend to the screen for the whole session, maybe they'll attend to the screen for, you know, a 
couple of minutes here or there. What we might use as an opportunity is for the SLP to roleplay 
with the parent. I might take out an activity that I have on my end and demonstrate the 
intervention with the parent, when showing them how I might do it. But on my end with a toy that 
I have, so then that way, they know how to use maybe even a different activity, a different toy at 
home. The important thing, though, is that the intervention is going to remain the same.

If I'm modeling with a Mr. Potato Head on my end, if the child decides that they want to play with 
a cooking set, for example, the intervention of modeling, and maybe following their lead, for 
example, is going to remain the same. I also think that's an important thing to explain to parents. 
While the activity might change, the intervention, and the way we implement that intervention is 
going to remain the same.

[0:12:57] KHK: Wonderful. Thank you for explaining that. What are some ways that in person 
parent coaching might differ when applying the strategies in-person versus telepractice?

[0:13:08] MR: So I think it really depends on the child, the goals, and the activities. If we have a 
kiddo who consistently is interacting with the SLP, so maybe they're a little bit older, or they are 
doing articulation, and they are sitting at their device for the entirety of the speech session, to be 
honest, there's not a huge difference in parent coaching strategies, as compared to in person. 
For example, you know what we talked about before, with maybe targeting articulation words, 
let's say, maybe I can share a game board up on my screen, and I tell the parent about the 
intervention that we're going to be participating in.

Let's say we're targeting dealer fronting, for example. I explain that to the parent, I explain what 
type of cueing we might use. Of course, I'm not going to use that language, I'm going to explain, 
"We are going to maybe give him the word, or maybe touch our throat right here to kind of show 
him that he needs to make the sound here." I'll explain that to them. Then, I will participate in 
that activity on screen with the kiddo, weÕll do the board game as the words are kind of coming 
up the board game that we're going to be working on. Then, I will invite the parent to do the 
same and the parent can actually participate on the screen that I'm sharing. It's even better if 
they're able to control the mouse because the two of them can take turns and it can be a little bit 
more interactive between the two of them.

All the while, I am really focusing on the parent and making sure that they are giving the cues 
that they need in order for the child to be successful. However, if you have a child who is 
intermittently interacting with the SLP on screen, let's say maybe they will participate with me for 
five minutes, and then maybe they need a break, maybe they need to get off the screen for a 
little bit, or maybe they go to another activity because they're really active, so they move from 
one thing to the next very quickly. In that case, this is where it differs a little bit from in-person, 
because in this case, the parent is going to have to be a little bit more, or maybe even a lot 
more hands on. 

We're on the other side of the screen. So as teletherapist, we don't have the ability to go get the 
child, and go see what they're doing, and go interact with them. We have to have the parent go 
do that. I think in that case, it really involves a collaborative relationship with the parent, maybe 
even more so than in-person, because the parent needs to be very involved. I think a lot of 
conversations prior to this happening really need to happen with the parents. So that way, they 
understand, okay, if the kiddo gets up, and moves to another activity, that's absolutely fine. 
We're prepared, we know what we're going to be having to do. 

This is also a case in which that role playing might be effective. That way, I can show the parent 
exactly how they're going to be using this intervention, and that way, they feel prepared. So that 
way, when they get to the Mr. Potato Head on their end, or the doll set on their end, whatever it 
may be, that way, they feel that they know what the strategy or the intervention is going to be. 
Then, as I'm observing, I will be providing feedback to the parent.

[0:16:24] KHK: I'm curious, a lot of questions are coming up in my mind, and I believe the 
audience might have similar questions. When you are working with the parent, where do you 
have them sit? Or where are they, ideally, in relation to where the child is?

[0:16:41] MR: Usually, I have them sitting right next to the child, ideally. There are some 
parents who do sometimes maybe like to be in the background, doing something else. I do ask 
that they, if possible, that they are with the kiddo, especially when we're implementing parent 
coaching, because it's so important for them to really understand the interventions and how to 
implement them. Because washing dishes in the background, they might be able to hear us, but 
they're really not going to be able to see and visualize what we're doing. Yeah, I usually have 
them sitting right next to them during our sessions.

[0:17:17] KHK: Have you ever had success with a parent maybe logging on through a different 
device? I'm curious.

[0:17:23] MR: That's a great question. I've had that maybe a year or two ago, with a parent who 
was not physically with the kiddo. So, I had one parent with the kiddo, and then another parent 
who was somewhere else, and they logged on. That was actually very successful, because the 
parents were so involved, and they really just took the implementation and the strategies and 
they kind of just ran with them. But yeah, it's an interesting thing to think about as well, the 
parent also being another participant in the session as well.

[0:17:59] KHK: Yeah. I mean, that definitely opens up so many options. If a parent's working or 
for whatever reason, they can't be physically in the same room as the child. What do you think 
made it so successful in this scenario that you were describing? 

[0:18:14] MR: I think in this particular scenario, the parent who had actually signed in from a 
different location was previously in other sessions, but physically there as well. That's not to say 
that maybe if they signed in consistently, they might not be able to participate as well. But I think 
that because the mom had such a great understanding of the strategies and how to implement 
them, she was really able to participate nicely with the kiddo from a distance, which was really 
great to see as well.

[0:18:46] KHK: I imagine that they probably worked on activities that required more screen 
sharing, rather than using real objects probably, correct?

[0:18:56] MR: Right. Right. Well, the thing with this kiddo too, he was one of the kiddos that was 
very active, and liked to move from one activity to the next. So, it was really the two parents, the 
one who was physically there and then the parent who signed in, that we're kind of collaborating 
with, "Okay, let's get out this toy," or, "Let's get out this toy." Then we kind of had coaching in 
the background, and you kind of maybe throw out some ideas for them.

[0:19:19] KHK: Love it. Love it. I was also curious if you use any kind of behavior strategies, or 
devices like timers when it comes to the kiddos that might not be able to sustain attention for 
very long?

[0:19:34] MR: Yes. For some kiddos who have difficulty sustaining attention, I really try to gear 
the activities towards their interests, and what are the things that motivate them the most, 
whether that be on screen or off screen. I even have some kiddos who sometimes, they might 
be playing with a train, but they're still looking at me, and they're physically playing with the train 
but we are still interacting. I think that has been very effective in just following their lead, and in 
doing the things that they're interested in. 

I also do occasionally share some timers as well. That has been very helpful, especially when 
breaks are needed. Because sometimes kiddos, maybe they're just not in a space that they 
were able to be on the screen for the full time during this session. They might need a break and 
that's okay. I sometimes need a break when I've been on the screen for a really long time too. 
Sharing a timer and having a very large timer, so that way they see, has been super, super 
helpful.

[0:20:38] KHK: That's great. I am also curious, when we say break, how do you give them a 
break, or what kind of activities do you do during the break to really make it effective?

[0:20:51] MR: Usually, what we'll do is we will tell the kiddos, "Hey, we are going to do a certain 
amount of time doing an activity," and then I might give them a one or two-minute break. 
Sometimes for them, it's a bathroom break. Sometimes it's a break to play with their toys. 
During that time, I usually don't go out of my way to necessarily interact at that time with them, 
because that is their time to just have as a break. But I do take advantage of that time to talk to 
the parent, because, I'm sure a lot of those therapists out there probably also have the 
experience where there's so much that we need to talk to the parent about. Sometimes, we get 
to the end of the session, and we have one minute left. So, using that break time to have those 
collaborative moments with the parents is really helpful.

[0:21:41] KHK: Definitely. Every moment is golden, that's for sure. Let's talk a little bit more 
along those lines. What considerations should we take into account for parent coaching via 
teletherapy?

[0:21:53] MR: There's so many things to think about. I think the first thing is that it's important to 
not assume that parents want to participate in teletherapy. I mean, of course, it's ideal that they 
do. But having a discussion with them, or even maybe multiple discussions with the parent or 
guardian about what parent coaching is, how it works, why we do it, and what to expect. 
Managing expectations is really important, managing our expectations and their expectations as 
well. I think that, you know, gauging their motivation; how motivated are they to participate in the 
child's therapy and carry it over into the home environment?

Usually, I find that in the first or the second conversation with the parent, I'll get a good sense of 
what their motivation is for parent coaching. Some parents call with that in mind. They want tips 
for home, and they want to know what they can do at home. Some parents do prefer that the 
SLP takes over, and does the teletherapy, or does the therapy. I think it's really important to 
kind of establish all of those things prior to then embarking on the parent coaching journey.

Another thing to consider is a parent's schedule. Every family member or every family has their 
own reasons for choosing teletherapy. Some families may choose teletherapy due to time 
constraints, or the fact that teletherapy is convenient, which of course, it is, it's wonderful. But 
they do this because they have busy schedules, or they have other commitments, or other kids. 
We also have to consider, if we say to them, ÒWe are going to give you all the strategies, and 
you're going to have to work from one session to the next. You're going to have to do a bunch of 
work,Ó we don't want them to feel like we're putting more on their plate than they already have. 
Which is why I think it's important to create strategies that they can fit into their everyday 
routines, so that not only did the skills generalize, but so that they also don't feel that we are 
putting more on their plate than they already have.

I also think that considering a parent's comprehension skills overall. Some parents do better 
with small pieces of information. Some parents need a lot of repetition. Some parents need a lot 
of demonstration. Some parents themselves might have comprehension deficits. We definitely 
need to be mindful of that. We also need to think about how parents learn best. Sometimes, I'll 
even ask them, ÒDo you prefer that I give you feedback in real time? Or do you prefer to interact 
with your child for a couple of minutes and then I give you feedback after? Do you want a written 
summary of what we've talked about?Ó So that way, they have a visual. Because every parent 
learns, just like children, we all have our different ways that we learn best.

I also think being mindful of the environment is really important too. In teletherapy, sometimes 
we can only see a portion of the room. We might really not know what's going on, who's there, 
maybe the TV's on, maybe the whole family is in the kitchen. We have no idea. It's important 
that we have conversations with parents about the best environments to do teletherapy, and to 
do parent coaching. 

Another thing to be mindful of is also thinking about maybe the device that they're using. For 
those kiddos who are more frequently on the move, I usually recommend a tablet, for example, 
so that way, they can see me on a bigger screen. But if the kiddo is going from one toy to the 
next, the parent can bring me around. In that way, it doesn't feel like it has to be so stable. 
Maybe for those kiddos who are able to participate in on screen activities for the entire session, 
maybe a desktop or a laptop would be more appropriate because they have the screen control. 
That's definitely something to think about as well.

I think another important thing to consider is that, as clinicians, we need to be confident in our 
own skills before we teach parents about how to use these interventions with their children, 
especially with teletherapy. Because, in teletherapy, like we said before, sometimes the parents 
do have to be more hands on. We have to make sure that we're confident in what we're telling 
the parents to do. Lastly, I think being mindful of the way that we present feedback to the 
parents. We want our feedback to be constructive, but we also want to be mindful of the parent, 
because we don't want it to come off as though there's any judgment. We want to give positive 
feedback as well as recommendations for next time.

[0:26:33] KHK: Well, a lot of really great nuggets in there. If you don't mind, I'm going to try to 
ask a few more questions to go a little bit deeper because I'm so curious. You mentioned that 
each parent is going to learn differently. We all have different styles and different manners that 
we learn best. I'm curious, what are some ways you go about gauging that? Is it just through 
trial and error or do you actually have a way of knowing what a parent's preferred learning 
modality might be? 

[0:27:05] MR: That's a great question. Usually, I will go to the first couple of sessions and just 
have those conversations with parents, providing them with the strategies, and then also those 
conversations about providing them feedback. I think sometimes with that, I'm able to gauge, 
ÒOkay, did they take in what I was saying, or maybe, do I need to change it out?Ó But I also think 
that even just asking them, ÒHow do you learn? What is the best way? What do you feel you 
need from this? How do you think that you are going to learn the strategy best? Is it going to be 
by me consistently modeling it for you? Do you need to watch me over two or three sessions 
before you start to implement these strategies? Or maybe, do you feel that you just need to 
watch me for 10 minutes? I think really just having those open conversations with those open-
ended questions are really helpful for parents.

[0:28:06] KHK: Excellent. Then, you talked about managing expectations. I think it's ideal if a 
parent knows what they want, and comes to you with that, right? Like they want parent 
coaching, so you know exactly what to do. What happens if, in your opinion, parent coaching 
might be a good option, but the parent is not on board, or they're not really willing to participate 
in that?

[0:28:30] MR: That's a tough one. It's really tough. Because like you said, ideally, the parent is 
going to want to participate in those interventions, because that's where we see a ton of 
progress from session to session. But I think that there may be a variety of reasons. Maybe the 
parent is already overwhelmed, maybe they feel like they might not be the best in-home 
therapist for their kiddo, maybe they feel like their kiddo isn't going to pay attention to them. I 
think that really goes along with empowering the parent, but not necessarily forcing them into 
something that they don't want to do. It's important that we are very mindful of their wishes. All 
the while, we can continue to educate them. I think that is key. If they come to me, and they say, 
they don't even necessarily have to say, it's one of those things that sometimes I can even tell Ð 
if they leave the kiddo at the screen, and then they go off into the other room, and then we just 
talk for five minutes at the end of the session. We can kind of tell, okay, "Maybe they're not 
interested in participating." I think with that, then it's just really important to tell them, "This is 
what we did today, and this is how we're doing it,Ó and just kind of educating them about the 
importance of the power really, of using these strategies at home.

[0:29:51] KHK: I love it. Thank you so much. I'm curious also about environment. You 
mentioned certain environments might be more conducive to parent coaching. Any comments or 
certain scenarios you might want to share of positive outcomes in an unexpected environment 
or an environment that we should avoid doing parent coaching?

[0:30:13] MR: Hmm, great question. I feel like one of the environments that is really conducive 
is always in the kiddos home, usually in a room that is quiet, if possible. I don't love sessions in 
the car. I actually don't think that that can be conducive at all to the parent-coaching aspect. 
Even, for example, outside on the playground, I think if there's good internet connection, and if 
the kiddo is one of those kiddos that loves moving around, and just really is going from one 
thing to the next, maybe they need to move their body, so if the parent is able to bring me to the 
backyard, and we're able to do parent coaching that way, what's working with the child, and the 
parents, then, by all means, I think those sometimes unexpected locations can be conducive to 
parent coaching. 

But it does have to be controlled in some manner. There has to be that internet connection. If 
we're on a playground, for example, there can't be a ton of other kids around, because then, it 
might be a little too distracting. Maybe in their backyard in the sandbox or something like that 
might be a good place.

[0:31:30] KHK: Wonderful. Thank you so much. All right. Let's see, we've covered quite a lot 
here. What programs are available for parent coaching?

[0:31:41] MR: There are quite a few. But there are a couple of things worth mentioning. Hanen 
is actually a program that is in-person and telehealth as well. They work with late talkers and 
autistic children. They work to train parents and provide feedback to parents to help them 
change their own communication skills with their children in order to help their children then 
change or improve their speech and language skills. This involves that collaborative relationship 
as well, that we were talking about. It involves setting goals with the SLP and the parents. There 
are group parent meetings where they're provided with information, they view videos, they have 
discussions, they problem solve, they reflect and they roleplay. 

There actually now is a certification specifically for SLPs who want to do this type of intervention 
via telehealth. If that's something that anybody out there is interested in, I would definitely 
recommend referring to the website to find out more information about the programs and more 
information about the research behind it as well. Another program or intervention is called 
DIRFloortime. This is a developmental approach that looks at the whole child. It works to 
promote development through meaningful reciprocal interactions with caregivers. This is all 
done through activities that the child is interested in.

There are actually two telehealth parent-coaching programs. One is for parents with children 
with neurodevelopmental differences from birth to 21. Then they also have another program for 
older adults with neurodegenerative diseases. Then also, in addition to that, in their training 
program for professionals, they have one course that is specifically related to parent coaching, 
and this can be done in-person or via teletherapy, as well. Again, if this is something that 
anybody out there is interested in, I definitely recommend referring to the website for the 
research and for more information about the programs.

[0:33:48] KHK: Would love to hear when you have used the Hanen approach in a particular 
case and what the outcome was, or if there were any specific challenges that you worked 
through? Then, we'll ask the same question for the DIRFloortime.

[0:34:04] MR: Sure. I'm actually not certified with Hanen. Full disclosure, I haven't taken the 
course. But it is an intervention that I did learn about in grad school. It is one of those 
interventions that I frequently use with the early intervention and preschool population. It really 
just involves providing, modeling, and providing those language stimulation techniques to kiddos 
who maybe don't quite have those first words yet, or also kiddos who are autistic. With that, I 
have done that kind of across the board with a lot of my parents and taught them how to model, 
how to recast, how to do the self-talk and the parallel talk. It's really great to see because a lot 
of the parents end up kind of just picking this up as their natural communication strategy with 
kiddo. Sometimes they come to me and the parent, by no fault of their own, might ask a lot of 
questions. Or they might say, you know, what color is this, or what's that called. 

So then, I kind of tried to work with them to then try to get them to model what the name of that 
object is, or what color it is. So that way, there isn't that pressure on the language for the kiddo. 
When we do that, the parent then kind of naturally changes their communication, which helps 
the child improve, which is pretty amazing.

In terms of DIRFloortime, it has definitely helped me work to follow the child's lead and their 
interest, and develop those meaningful interactions with the child. While I'm learning it right now, 
I've also helped parents as well. When we talk about meaningful, reciprocal interactions, we can 
be talking about eye contact, or facial expressions, or gestures. It doesn't have to be any type of 
verbal language, because these meaningful interactions that are these back-and-forth 
interactions with parents, this is the building blocks for language. These are these pre-linguistic 
skills that we need before language comes in. 

I really do love working with parents to talk to them about working on those pre linguistic skills 
before we even get the language in, and seeing them work towards those interactions with the 
children just by following the child's lead and going with what they're interested in, and entering 
into play with a child without having any agenda, or without having any plan as far as what we're 
going to do and kind of just going with it. It has been really great to see parents kind of change 
in that way to then allow their children to initiate and communicate with them.

[0:36:57] KHK: Excellent. I'd love to hear an example of how DIRFloortime might work for the 
older group that you mentioned, or older adults. Any examples of that by chance?

[0:37:10] MR: I have a client who is about 20, and he is diagnosed with autism. During our 
teletherapy sessions, I'm able to ask him questions, and he may respond, but sometimes he 
might not ask me a question or he might not initiate. What we've been doing has been, I have a 
dog, and recently, I was fostering a dog, I would actually bring him over to the dogs and mom 
would be present. She'd be sitting next to him and we would kind of just talk about the dogs. 
Because he loved the dog so much, he would go, "Oh, how cute." And we would kind of just go 
along with it.

I think by us holding back and letting him tell us what he was interested in, and really seeing the 
smile on his face, really just cued us into, ÒOkay, this is where it's at. This is where we're going 
to get our communication in.Ó Himself, and his mom, and myself, we had a little conversation 
with the three of us. Whereas, previously, we might play checkers, for example, and there 
wasn't a ton of that there. It wasn't a back-and-forth reciprocal conversation. It was more me 
asking questions, or me giving him flashcards, or something like that. 
It has been super effective with the older population as well.

[0:38:39] KHK: Very interesting. I didn't know that there was this other program for the older 
adults, so that is fascinating. All right. Let's talk about the research behind parent coaching. 
What's the evidence that's out there?

[0:38:53] MR: In general, I laugh because more evidence is needed. But what we are seeing in 
the literature is that some of the most effective treatment involves parent coaching via 
teletherapy. One example is a program called Impact. This is improving parents as 
communication teachers, et al. This worked with parents of autistic children ages birth to seven. 
The parents received coaching sessions, either in-person or via teletherapy. They were 
coached to use modeling and expand on their children's language. They were also coached in 
how to interactively play with their children. Then, lastly, they were coached for how to scaffold 
according to their child's expressive language.

For example, meeting the child at the cueing level that they needed, whether that be modeling, 
or giving them a visual cue or verbal cue, kind of just depending on where they are. Or maybe 
even, if they are at the two-word level, speaking at the three-word level, depending on what their 
needs are. With this study, parents actually improve interactions with their children, and their 
children's MLU increased as did their lexical diversity, indicating that parent coaching via tele 
therapy can be just as effective as in-person parent coaching.

[0:40:17] KHK: Love it. Love it. How about evidence that's specific to supporting parent 
coaching strategies among the early intervention population? Anything there? 

[0:40:27] MR: Yes. From what I've seen actually, I feel like most of the evidence is geared 
towards early intervention and preschool language. One example is Parent Implemented 
Communication Strategies, which is a program. The research looked at this online-based 
intervention, which targeted expressive language in the early intervention population. It worked 
with parents as they were reading a book with their children. The parents first participated in 
coaching sessions via Zoom, and then they received feedback when working with their children 
using the intervention. Very similar to what we were talking about, with what parent coaching is. 
The results indicated that when parents were taught to pause more during interactions, children 
are more likely to initiate. Children are also noted to increase single word utterances as well as 
their use of phrases. 

In addition, Enhanced Milieu Teaching has also been researched by Quinn, et al. This is a 
hybrid in-person and teletherapy program to coach parents. In this particular study, they 
researched modeling, incidental teaching, and time delay using a teach model coach review, 
which is what they called it. Very similar to what we were talking about before, where we share 
knowledge with the parent, we model it for them, we then coach them and provide them 
feedback. Then after that, we have a conversation with the parent to talk about how it all went. 
The results with this indicated that there was an increase in communication intent and different 
numbers of words in children. All really good things pointing to early intervention strategies for 
parent coaching via teletherapy.

[0:42:11] KHK: Amazing what can happen if a parent just pauses and waits a little bit. I love it.

[0:42:16] MR: I know. I love it.

[0:42:20] KHK: All right. Then let's talk a little bit about older children, school-age children. Is 
there any evidence to support parent coaching for that population?

[0:42:30] MR: Yes. As I said, a lot of it is geared towards the early intervention and preschool 
population. But some of the evidence is also available for the school-age population. This is 
specifically with respect to language. One example of this is Nelson, et al, which examines the 
efficacy of parent coaching via teletherapy that targeted inferential language. This is more 
literacy-based. This is talking about the ability to understand what is not explicitly stated while 
reading a narrative. They worked with parents of children who are boys with Fragile X 
Syndrome between the ages of 10 and 17, and this is all through teletherapy.

This study was actually one that was a follow up of a previous study by the same authors, in 
which they studied language expansion in the context of shared storytelling. That proved to be 
effective. In the current study, this revealed that parent coaching via teletherapy, or by doing 
this, their children improved in their use of inferential language. It seems to be more language 
and literacy-based for the older kids.

[0:43:41] KHK: Could you give us an example of how they might use language expansion in 
shared storytelling? I'm pretty sure I understand what you mean, but I just wanted to make sure 
everyone listening understood that as well.

[0:43:53] MR: Sure. For example, if we are talking about maybe a narrative that we read with a 
book, or maybe even an event that happened, we're talking about the back-and-forth reciprocal 
communication with the parents while the child is able to use phrases or sentences, whatever 
the level that might be at. Maybe what the parent might do is expand on what they've said. It's 
kind of similar to what we do with the younger population. If a child says or the school-age child 
says maybe a phrase, maybe the parent can kind of recast by maybe rephrasing, or saying 
what they've said, and reinforcing that, but maybe adding a little bit more information. Or adding 
some syntactical or semantic information to help them expand on their language.

[0:44:47] KHK: Thank you. That was very helpful. I appreciate that. All right. Now, based on 
research, what would you say are the most effective strategies used for parent coaching?

[0:44:57] MR: I think for early intervention and the preschool population, definitely modeling, 
incidental teaching, which is where we work to target a specific word or skill as it organically 
presents itself in an activity. This actually lends itself really well to parent coaching, because this 
is great for parents. If they are giving their child a snack, or maybe they are Ð their child is taking 
a bath. They can use incidental teaching or use these strategies in incidental teaching as they 
kind of naturally come up. They can use time delay.

For example, maybe a child comes to me with a ball, or a toy, or something like that. Maybe I 
wait to see what they do, or maybe I wait to see what they say, and then I go in. By giving that, 
just like you said, by giving that time, it really allows them to then initiate. Then, we've also Ð 
which is also interesting is that we've seen, by reducing the communicative pressure, that 
definitely improves language growth in our little kiddos. By not asking so many questions, by not 
asking the questions that we already know the answer to. I think that asking questions is, there's 
definitely a time and place for it. Sometimes it is necessary, and sometimes we're teaching that. 
But for our little kiddos who are just learning language, or maybe you're still working on those 
great linguistic skills, definitely reducing that pressure for them, helps them, then again, initiate 
and expand their language.

Then, of course, language facilitation techniques, such as self-talk. Maybe I will just talk about 
what I'm doing when I'm playing with the dinosaur, parallel talk, talking about what the kid was 
doing. Allowing for silence when we're playing, so that way, there isn't a ton of pressure there. If 
I'm consistently talking while the kid was playing, then there is no room for them to 
communicate. I think that teaching those skills to parents is super helpful to expand their 
language. Then in terms of our school age population, parents have been successful when 
coached how to use verbal prompts, or open-ended questions, modeling, expanding, kind of like 
we just talked about before, recasting. Those things have been super helpful in terms of 
outcomes for children's speech and language skills with parent coaching.

[0:47:35] KHK: I think it's such an important reminder to not have those pressures when 
speaking. I just think of all the parents that are constantly asking their child to label. What's that? 
What's that? Or say, "Blank." Say, "Blank," when they really can't. It's really a great reminder 
about that. Let's talk a little bit more about the outcomes. What speech and language outcomes 
can we see with our clients whose parents participate in parent coaching via teletherapy? 

[0:48:09] MR: I think the biggest thing is generalization. As therapists, as SLPs, and SLPAs, we 
only see the client for a very small period of time throughout the week. Maybe it's a half hour, or 
maybe it's an hour. That parent coaching piece is so important, because the parent or the 
caregiver, or whoever it may be is with the child for the rest of that time. When the parent really 
does participate in parent coaching, via teletherapy, and when it's effective, we see the 
generalization of skills. We can see improvements in expressive language skills, improved 
vocabulary, improvements in literacy skills, and articulation as well, when we have parents who 
are coached on how to work on specific target words and goals with kids.

[0:49:08] KHK: Then, before we go further, what are some measurable ways to target speech 
and language outcomes for parent coaching? How would you write a measurable goal, perhaps 
a smart goal for parent coaching?

[0:49:23] MR: Great question. I've actually never specifically written goals for parents. I might 
have notes on my end about maybe how the parent is doing in terms of their level of 
comprehension of the different interventions, or maybe where we left off last session. But really, 
I write the goals for the children or for my clients. Then. of course, I'll share those goals with the 
parents. Really, when we start to see the improvements in the goals with our kiddos, that's 
when we start to know that the parent coaching is really being effective.

[0:50:05] KHK: That's really a good point, so you don't necessarily have to write the goals from 
the parent's perspective, it can still be through the child's perspective. I love that. All right. Then, 
I'm curious how you would measure outcomes for generalization of articulation goals when 
you're using parent coaching. 

[0:50:24] MR: Sometimes what I'll do, and I don't do this for every session, but when I'm 
coaching a parent, what I might do is take a data count at the end of one session, and at the 
beginning of the next session. It might even be like out of five trials or out of 10 trials. That way, 
I can really see that between the last session, and the current session, "Oh, wow, there's been 
some improvements." It looks like they have been practicing at home. Then also, just checking 
in with parents at the beginning, and or end of each session. Sometimes, I'll ask that open-
ended question. How did it go this week? Usually, they know what I'm referring to.

In my experience, parents are usually very upfront about whether or not they practice. 
Sometimes, they might even say, "You know what, this week was a holiday. We didn't get much 
practice in. That's actually fine, because they do know that consistent practice is what leads to 
us improving our goals, but sometimes it does get to be a lot. I definitely tried to check in with 
parents, though, and make sure that they have what they need in order to be able to implement 
those strategies from week to week.

[0:51:42] KHK: Great advice. Can you share some specific cases where parent coaching 
improved outcomes for your clients?

[0:51:50] MR: Sure. I have one little kiddo who started with me a couple of months ago. Her 
mom came to me and said, "She has a couple of single words here and there, but she just 
spent the entire day with these long strings of utterances that I just can't quite understand." 
She's going on, and on, and on, and I'm just not quite getting it. We started our sessions and 
actually, came to find out that this kiddo was a gestalt language processor. She communicates 
using echolalia. The long string of utterances was actually jargon and these were actually 
scripts. It's just that the words hadn't quite fit themselves into the scripts yet, or the delayed 
echolalia. During our teletherapy sessions, this kiddo was quiet with me. I mean, she was super 
interactive on screen, really engaged. She would give me some vocalizations here and there, 
and sometimes in gestures. All the while, mom was sitting next to her the whole time.

I did a couple of sessions of just me and her, because I wanted to kind of gauge where we were 
at. Then after a couple of weeks, mom actually sent me a video of her, of herself playing with 
her daughter. It was a completely different story, because I heard the jargon. I mean, this kiddo 
was just going on, and on, and on, and on. I think it's really important because I was able to see 
the difference between what I was seeing in the session and what I was seeing at home. So 
then, what I did was, I coached mom in our sessions to work on just following her lead, allowing 
her to initiate. doing activities that really interested her and modeling. That was the main thing 
that we worked on, just modeling new phrases for her to learn. That would have been functional. 
Things like, "Oh, we did it" or things like fun. "Oh, that's fun." 

After a couple of weeks, I mean, mom really just kind of picked up all of these strategies, and 
just flew with them, which was really cool to see. After a couple of weeks, mom comes to me 
and she says, "It's really amazing. All of her jargon is now Ð I'm hearing the words, because she 
is feeling more confident, and coming up to me, and telling me what she wants to tell me 
because I'm understanding her better. The modeling is really helping because I'm listening to 
her, you know, then repeat the models, and I'm not even asking her to repeat them." That's what 
I told mom, "Let's not ask her to repeat the models. We're just going to model and we're going to 
see what happens."

This kiddo is now using more phrases. She's definitely expanded the amount and the types of 
phrases that she's used, which was really, really amazing. It's really been cool to see that I've 
only kind of been just a catalyst in this. I really just kind of taught mom how to model. I gave her 
a bunch of resources, we practiced every session, and I gave her some feedback during the 
sessions. But, yeah, it's been really great to see the increase in expressive language that this 
kiddo has had.

[0:55:26] KHK: I think you really encapsulated that well. Parent coaching is basically the 
catalyst. That's awesome to hear that. Would love to hear another case if you have one.

[0:55:38] MR: Sure. I also have a kiddo who I just started working with, who came to me with a 
bunch of phonological processes that were impacting his intelligibility. We started with final 
consonant deletion. We started with the consonant vowel, consonant structures. Where it's like, 
sit, and hat, and boot, and boat, things like that. This kiddo loves the onscreen activities, he 
enjoys any of the board games, Tic-Tac-Toe, Connect 4. It's been really great and easy to also 
get Mom involved in onscreen activities.

What I did was, I started working with him, because I wanted to kind of gauge how he would 
respond to the strategies first, and in the implementation of the intervention first. He picks up on 
it pretty quickly within the first session. Then, actually, within that first session, I involved mom. I 
explained to her how we were going to model the target word. Then I also explained to her what 
might happen if he produces the target word, even with the model incorrectly. What else do we 
need to do? Do we need to give him a verbal cue or a visual cue? 

I then kind of handed it off to mom, and I let her participate in the activity with him, with the 
target words. I just love working with the parents who are just so involved, and they're just right 
there, and in it with the kiddo, because she picked it up so quickly. To be honest, I didn't have to 
do a ton, I kind of just had to say, "Okay. Let's give him the model maybe before he says the 
word" or, "Oh, we forgot that one" or "Let's make sure we get that sound in there." 

From the first session, to the second session, the kiddo came back with all of those target words 
completely independently. We went from using modeling and visual and verbal cues to then, in 
the second session, those target words being completely independent. Then, we moved on to 
other targets. Now that mom is independent herself in cueing him, and in reinforcing his targets 
that he does well with, it's really just a matter of our sessions now just me having some time with 
him to participate in the intervention, and then I hand it off to mom. Then I kind of give any 
feedback that's needed. In the same way, I'm kind of just the catalyst. It's kind of cool to Ð I don't 
want to say, be hands off because I'm still there and I'm still giving that support. But it's really 
great to be able to empower the parents so that way they know what they need to do when I'm 
not there.

[0:58:46] KHK: Absolutely. I just wanted to remind the audience if there's any questions that 
you would like asked to Megan at this time, it's a good time to put your questions into the chat. 
While people are maybe gathering their thoughts, if you wouldn't mind kind of summarizing 
everything that we've been talking about for the past hour.

[0:59:09] MR: Of course. I think that the common denominator that we're seeing in all of the 
research is that parent coaching via teletherapy is effective. There are definitely a lot of things 
that we need to consider, but I think that if we are on board, and we're confident in our skills, 
and the parents on board, if we start having those conversations. I think that the parent 
coaching piece can be incredibly effective. Parent coaching doesn't have to happen right from 
the first session. Sometimes we need to go quite a few sessions before we add it, and it's not 
something that we need to jump right into. But in seeing the outcome that it's hot, and the 
research, and even personally with my kiddos, there are a ton of wonderful outcomes, such as 
increased vocabulary, MLU, enhanced literacy skills, expanded language, improvements for 
articulation. Yeah, I'm a big fan of parent coaching via teletherapy.

[1:00:24] KHK: What kind of advice do you have for SLPs or SLPAs who are just beginning to 
use this model?

[1:00:32] MR: I definitely think that, just kind of taking it slow. Like I said, we don't Ð it's not 
something that you necessarily need to jump into. But even just having those conversations with 
parents about what to expect and letting the parents know, this might be something new for me, 
so we're going to try it out together, and we're going to go through it together and figure out how 
it works. Sometimes, parent coaching is just trial and error. It's just seeing what works for the 
family dynamic, seeing what works for the client. I think that just taking it piece by piece and not 
really rushing into it might be helpful.

[1:01:15] KHK: Well, thank you so much. All right. Thanks. Again, we truly appreciate your 
research, education, and expertise. You provided about Empowering Parents via Teletherapy: 
Early Intervention to School-Age Children. As a reminder, if your state license requires CEUs, 
be sure to complete all course modules, including the one that says "Quiz" before the end of 
today on your SpeechTherapyPD.com account. Please be sure to join us for our next episode in 
the series, episode six, Treating Medical Cases Through Telepractice. Have a great evening.

[1:01:52] MR: Thank you.

[END OF INTERVIEW]

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SLPL S7E5		Transcript
	© 2023 SLP Learning Series	1