Preface: I was both honored and excited when Judy Kuster invited me to take part in this innovative ISAD conference by asking me to present a paper on "The Internet and Therapy for PWS." As I began to prepare this paper, I found myself trying to cover the broad range of discussion lists, web sites, search strategies, email and chat opportunities that are currently being employed in the treatment of fluency disorders. However, I decided to focus my efforts on the preliminary studies that have been conducted by my students using low-cost video-conferencing for the provision of treatment to remote clients. Although our attempts thus far have not included PWS, I believe that many forms of stuttering treatment may lend itself to this form of remote intervention. I am in the process of designing and conducting two studies which will examine the effectiveness of this approach to the "remote" treatment of stuttering.

Introduction
Video-conferencing (VC) is the combination of dedicated audio, video, and communication network technology for "real-time" interaction. It is used by individuals in one setting to communicate with other individuals who are at a remote location. The two main types of VC are dedicated group-system conferencing and personal desktop video-conferencing (DVC). Video conferencing was a tool for the "business-elite" until the early 1990's. Until 1994, DVC was almost non-existent. However, with the proliferation of technology and digital communication, the fields of education and medicine have embraced VC technology.

You may not have frequently heard the term video-conferencing used in the context of education, although you surely have heard of "distance learning." Distance learning is the incorporation of audio and video technologies into the educational process so that students can attend classes and training sessions in a location distant from that where the course is originating. Today, schools in virtually every state participate in distance education projects involving a variety of technologies used for everything from international student interactions to inter-district staff meetings.

As with distance education, telemedicine is growing and is being utilized with increasing frequency by health care providers. In the Fall of 1997, ASHA focused its association's magazine on the topic of Telehealth. Telehealth or telemedicine uses electronic signals to transfer medical data (e.g., high resolution photographs, radiological images, sounds, patient records, video-conferencing) from one site to another. The Telemedicine Research Center (TRC) lists several medical specialists that are currently utilizing telemedicine in a variety of applications. Telemedicine offers many advantages to healthcare providers. Physicians can remotely monitor and treat patients which frequently decreases the number of days patients remain hospitalized. Telemedicine also permits visiting nurses to "visit" without traveling to the patient's home; a desirable alternative in rural areas. There is a continually growing number of medical specialties employing this technology.

The appeal of being able to "visit" a patient or client who resides in a remote area (e.g., rural home or in a different region or state) or interacting with the client who requires frequent/daily contact without traveling outside one's office or clinic is obvious. This type of approach may have a considerable impact on health care provision and costs. That is, service providers can provide "service" in a more efficient manner, seeing many more clients, because they can eliminate travel time to visit each client. A second issue relates to those individuals who are going without or are receiving only "token" intervention due to the difficulties of transportation or because an "expert" is not available in their general geographic region. With VC, the client and service provider (physician, clinician, nurse) can make frequent contact, both visually and auditorally, in "real-time" across town or across the world. Distance becomes a non-issue.

With such a great solution for such common challenges, why hasn't VC come a routine procedure? The answer to this question relates to the current level of readily available technology and the experience of service-providers (e.g., clinicians). The great news is that technology and technologic applications continue to proliferate at a stunning rate. Desktop video conferencing (DVC) is only four to five years old and is improving on a monthly basis. This technology application is dependent not only upon computer hardware and software but also on network communication and the internet. To better understand the potential of DVC and the challenges that still need to be overcome, it is important to briefly review the technology involved in DVC.

Desktop Video-Conferencing Technology: An Overview
All video-conferencing systems, be it an expensive room-based system or a desktop system, include a number of the same important components: a microphone that captures voices, a camera that captures images, a digitizer that converts the audio and video input into the necessary digital form, a CODEC (Compressor/Decompressor) to compact the digital signal for more efficient data transfer, and a communication network on which to transmit and receive the signals; most likely the internet. Each of these components will be reviewed from a DVC perspective.

Microphone - Most computers today are multimedia compatible which means they are equipped with audio capture and playback capacities. In this type of computer configuration, the computer can have a microphone (cost ranging from $10 to several hundred dollars depending on quality) and speakers (again costing from $10 to several hundred dollars depending on quality) interfaced with the computer to allow the user to record and/or playback audio signals. All computers manipulate digital information in their processing functions. The purpose of this audio capture/playback capacity is to convert the audio signal into a digital code, in the case of recording, or from a digital form into analog sound signals, in the case of playback. This conversion of the audio signal into a digital form results in a large amount of information that needs to be processed by the computer. In the case where this information is going to be shared over a network (e.g., the internet), it is desirable to reduce the amount of this information in a manner that will not greatly erode the signal. This requires some form of compression (discussed below).

Video Camera - As with the audio capacity mentioned above, multimedia computers are frequently able to capture and display video images. Low cost video cameras that interface directly with computers are available from various companies. These cameras, (see Table 1 below) which cost between $100 and $900, will "plug-in" to one of the ports on your computer and come with the necessary software to capture the video image and convert it into digital codes. As one can imagine, this video capture also produces a very large amount of digital data that is processed by the computer. Again, in the case where this data is to be shared over a network, it is necessary to compress this data prior to transmission (sending it over the network/internet).

Audio and Video Codec - Compression of the audio and video data prior to transmission and then the decompression of the data following transmission is accomplished through audio and video codecs. A codec is typically integrated into computer software involved in DVC (see Table 2 below). The audio and video information that has been captured produces a very large volume of data. The codec reduces the amount of this data requiring less bandwidthto transmit this data. Bandwidthis the amount of information that can be transmitted over the network and relates to the speed rating of your network connection (typically a modem). The smaller the amount of data to be transmitted and the larger bandwidth capacity of the communication network involved, the more efficient the video-conference is in regard to audio and video quality. In general the larger the bandwidth and the faster your modem or network connection is, the better the transmission and reception of the audio and video signals.

Communication Network - The communication network relates to the network your computer is connected to. This for most individual homes is a modem and a specific internet service provider. For corporate and most academic environments, the communications network (e.g., ethernet) is some type of system which physically connects computers (via cables) to a main computer (server), to one-another, and to the internet. In most cases, modem connections are slower (have less bandwidth) than dedicated (ethernet) connections. When communicating between a fast ethernet network and a modem based connection, the data can only be transferred at the lowest rate across this connection. That is, efficiency and quality of the transmission is limited by the slowest or smallest bandwidth of a particular connection.

Putting It Together - To summarize the components of DVC, it may be best to follow a capture and transmission from one individual to the reception of the signal at the other end of the connection. If I were to connect via DVC with you on your computer, I would sit in front of my video camera and microphone and talk to you. (In most video conferencing programs, you can concurrently send typed information similar to a computer-based chat roomalong with the audio and video signals.) The microphone and video camera would capture my audio and video images and convert these into digital data. This digital data would then be compressed and transmitted via our communication network (most likely the internet) from my computer to your computer. Upon receiving this data, your computer decompresses this data and processes the information reproducing the audio and video images on your computer. This is done in "real-time." (There is a slight delay which is dependent on the bandwidth (modem speed) of our connection and traffic on the network). You can respond to my communication by speaking in front of your video camera and microphone and the process is reversed resulting in my receiving your image and audio message. It should be noted that most current DVC systems will allow communication only in one direction at a time. That is, you have to wait to receive a message prior to responding.

Desktop Video Conference: Experiences
I have spent the past three years working on the mastery of DVC primarily through the use of CU-See ME software that was originally developed by Cornell University and more recently marketed by WhitePine Software. To be honest, my early attempts of this technology were focused on interacting with a couple of friends and family members from different areas of the country. My early DVC activity was very frustrating, having as many failures as successes. Since my first attempts, all aspects of this type of technologic application have improved considerably. The internet continues to grow and improve in data transmission, modem speeds are frequently increasing, and the general processing speed and capacity of computers continue to increase. The net result is more successful and efficient DVC via the internet.

Approximately one year ago, I began working with two students here at UNI who were interested doing research involving computer technology in the treatment of communicative disorders. The first student conducted a pilot project with an individual exhibiting the early signs of senility who was a resident at a long term care facility in our community. This individual, a retired professor, was institutionalized due to his physical, not cognitive, limitations. This individual was selected because he was an experienced computer user and had a wife who was very interested in participating in this project. Following several visits to the nursing home to establish a rapport with the subject and to train him and his wife, the student attempted to interact with the subject via DVC for two sessions each week. Data acquired related to the stability and quality of the connection, as well as to the ability of the subject to understand and respond correctly to auditorally presented questions and visual gestures. Although there were several frustrating sessions and others that were missed due to an inability to connect, it was concluded that this was a reasonable approach to provide a supplement to treatment or a compromise where direct face-to-face interaction was not possible.

The second student designed and implemented a study using DVC to supplement therapy in two young children exhibiting articulation and language deficits. This project involved these two children coming to our speech and hearing clinic for direct face-to-face treatment one day a week supplemented remote therapy via DVC two times a week. In each case the remote session included the mother of each child connecting with the student via an internet DVC and sitting with the child in front of their home computer (in a neighboring community approximately 20 miles away). The student researcher/clinician directed therapeutic activities via the DVC and was able to make clinical observations and judgments from his remote location. This study was recently completed and it was concluded that (1) this type of intervention is useful as a supplement to face-to-face therapy, (2) it is necessary to have a person who is technologically capable to use and problem-solve technology problems on the client's end of the connection, (3) subtle visual cues are not easily observed via DVC, and (4) the overall stability of the system continues to need improvement. This last conclusion relates to the situations when, due to a variety of factors, a connection can not be made and/or maintained.

Desktop Video-conferencing and PWS
From the onset of my interest in DVC, I have held a strong belief that this type of remote intervention may be best used in providing therapeutic interaction with adults who stutter. I believe that some of the challenges related to the stability and speed of the network connections may be minimized in some situations (viz., controlling the time and therefore the network traffic during DVC activities and connecting over an intranet("in-house" network). I am currently in the design phase of a study which will examine the efficacy of the provision of remote intervention to students who stutter on my campus. I am hopeful to find a small sample of individuals who live in the dorms who would be interested in participating in therapy from their dorm room two days a week and come to the clinic one session a week. My intention in having this occur completely on campus relates to the bandwidth/speed of the university network (this is much greater that connecting over the internet via modems).

A second project is to identify PWS (preferably adults with computer skills) who reside in my community (Cedar Falls, Iowa) who would like to participate in a manner similar to the students (presented above). I am in a unique situation where our municipally operated utility company has recently installed a fiber optic communication network in our community. This network also provides bandwidth and transmission speeds greater than those achieved over the internet via modems.

In both of these situations, I am optimistic that there will be considerably improved connections enabling more effective video-conferencing. This should enable the PWS and the clinician to have meaningful therapeutic interactions which will supplement the direct face-to-face treatment received in our clinic.

One may argue, what good does it do to examine efficacy of the provision of remote therapy on local networks (intranets)? My response is that based on the history of technology advancement, the not so distant future will provide the capacity (bandwidth and transmission) to conduct this type of intervention over great distances via the internet. I agree that there are problems with the current DVC technology, however, DVC has come a very long way over the past four to five years and there is a common expectation that it will improve over time.

Summary
DVC as a means of providing remote treatment for PWS may not be a substitute to direct face to-face treatment today, however, I believe that with the continued proliferation of technology, the use of DVC to supplement intervention may not be far away. This technology may provide the opportunity for someone who is not able to receive face-to-face therapy due to their location, to receive remote intervention. It may also be the way in which PWS and/or their therapists can interact with experts from other regions of their country or other countries in an attempt to better understand and/or control their stuttering. Further, I have used this technology to enable a child who stutterers, to interact with a peer in another state, because I could not locate another child who stutters to share with my client. In closing, it appears that the use of DVC for the provision of remote stuttering intervention is more than a myth. It is likely that this technology will become a useful and welcomed tool in the not so distance future.

Low-Cost Video-Conferencing Software