JCPSLP Vol 23, Issue 1 2021

Journal of Clinical Practice in Speech-Language Pathology Journal of Clinical ractic i Spe ch-L l

Volume 13 , Number 1 2011 Volume 23 , Number 1 2021

Speech pathology: An agile and responsive profession

In this issue: Agile and responsive service delivery including telehealth for rural locations Improving practice through clinical research using single-case design Student-led innovative intervention models Best practice decision making Impact of COVID-19, top-tips, current research and ethical conversations

Print Post Approved PP352524/00383 ISSN 2200-0259

Speech Pathology Australia

Acceptance of advertisements does not imply Speech Pathology Australia’s endorsement of the product or service. Although the Association reserves the right to reject advertising copy, it does not accept responsibility for the accuracy of statements by advertisers. Speech Pathology Australia will not publish advertisements that are inconsistent with its public image. 2021 subscriptions Australian subscribers – $AUD106.00 (including GST). Overseas subscribers – $AUD132.00 (including postage and handling). Institutional rate – $AUD330 (including GST). No agency discounts. Reference This issue of Journal of Clinical Practice in Speech-Language Pathology is cited as Volume 23, Number 1, 2021. Disclaimer To the best of The Speech Pathology Association of Australia Limited’s (“the Association”) knowledge, this information is valid at the time of publication. The Association makes no warranty or representation in relation to the content or accuracy of the material in this publication. The Association expressly disclaims any and all liability (including liability for negligence) in respect of use of the information provided. The Association recommends you seek independent professional advice prior to making any decision involving matters outlined in this publication. Copyright ©2021 The Speech Pathology Association of Australia Limited. Contributors are required to secure permission for the reproduction of any figure, table, or extensive (more than 50 word) extract from the text, from a source which is copyrighted – or owned – by a party other than The Speech Pathology Association of Australia Limited. This applies both to direct reproduction or “derivative reproduction” – when the contributor has created a new figure or table which derives substantially from a copyrighted source.

Level 1 / 114 William Street, Melbourne, Victoria 3000 T: 03 9642 4899 F: 03 9642 4922 Email: office@speechpathologyaustralia.org.au Website: www.speechpathologyaustralia.org.au ABN 17 008 393 440 ACN 008 393 440 Speech Pathology Australia Board Tim Kittel President Chyrisse Heine Vice President Communications Maree Doble Vice President Operations

Electronic copies of JCPSLP Speech Pathology Australia members are able to access past and present issues of JCPSLP via the Speech Pathology Australia website www.speechpathologyaustralia.org.au/ publications/jcpslp Electronic copies of the full journal or individual articles are available to everyone (members and non-members) at a cost by emailing pubs@speechpathologyaustralia.org.au or by completing the form available from the Speech Pathology Australia website

Kathryn McKinley Brooke Sanderson Alison Smith Bronwyn Sutton

JCPSLP Editor Editor Dr Leigha Dark c/- Speech Pathology Australia

Editorial Committee Emma Finch Rachael Unicomb Laurelie Wishart Cori Williams Shaun Ziegenfusz

Copy edited by Carla Taines Designed by Bruce Godden

Contribution deadlines Number 2, 2021 30 April 2021 Number 3, 2021 30 August 2021

Advertising Booking deadlines Number 2, 2021 8 April 2021 Number 3, 2021 17 August 2021 Number 1, 2022

1 December 2021

Please contact the Publications Manager at Speech Pathology Australia for advertising information.

Speech pathology: An agile and responsive profession

From the editors Drs Andy Smidt, Katrina Blyth, and Leigha Dark

Contents

2 Speech-language pathologist practice changes in telehealth speech-language therapy for rural children – Jessica Campbell, Deborah Theodoros, Trevor Russell, Nicole Hartley, and Nicole Gillespie clinical research: Using single- case experimental design to answer a clinical question – Samuel Calder, Mary Claessen and Suze Leitão 10 Improving practice through 16 Client and student perceptions of a group-based, student-led service model “Dysphagia Afternoon Tea”: A feasibility study – Shelley Gapper, Rachel Wenke, Melissa Lawrie, and Elizabeth Cardell 25 What is best practice when conducting decision-making capacity assessment of patients in the hospital? – Tracy Sheldrick, Alex Barwick, Paul Butterworth, and Nasim Salehi decision to have a tongue-tie released: A preliminary study – Anna-Maree Bennett, Grace E. Vincent, and Barbra Zupan 40 Viewpoints: Speech-language pathology: An agile and responsive profession – Bea Staley, Jenny Lethlean, Paul and Pat Cheetham, Ciara Spillane and Sharmin Kalantari, Rachel Davenport and Nikki Worthington 44 Top 10: Responsive speech- language pathology services during COVID-19 and beyond – Madeline Raatz 34 Factors that influence the

From left: Drs Andy Smidt, Katrina Blyth, and Leigha Dark

W elcome to the first issue of JCPSLP for 2021. First, we’d like to acknowledge the amazing work of Dr Leigha Dark who stepped into an interim editor role in 2020 and has been helping us to learn all we need to know to fill her very big shoes. Second, we’d like to take this opportunity to reflect on the last year. In March 2020 we were in the midst of uncertainty and rapid change as COVID-19 impacted all of our lives. Over this last year, we’ve all needed to re-think and adapt within our personal and professional lives. Like many of you, this caused an extra layer of stress! On a more positive note however, the global pandemic and international shutdown meant that we had the amazing opportunity to challenge our “old ways” of working and accelerate towards Speech Pathology Australia’s 2030 vision. The purpose of this issue is to share insights and highlight the responsiveness of our profession. The papers we have in this issue cover paediatric and adult services either in-person or via telehealth and illustrate the diverse range of our profession. Jessica Campbell and her team qualitatively explore practice change themes between face-to-face and telehealth delivery for young kids and their parents within a rural paediatric service. Perspectives from clinicians and managers are also presented. Samuel Calder explains how to answer a clinical question using a single case design. His paper is a great example of clinical research using a realistic sample size. Shelley Gapper and her colleagues present an innovative approach to educating people with dysphagia with student speech pathologists running a Dysphagia Afternoon Tea. This project provided clinical experience for students as well as opportunities for socialisation for attendees and their carers. Tracy Sheldrick and colleagues look at best practice when determining decision-making capacity of patients in the acute care setting. They look at current practice and the impact of communication on decision-making capacity. They advocate for the inclusion of speech pathologists as key to this process particularly in the presence of complex communication needs. Anna-Maree Bennett and colleagues address the perspective of carers who chose to pursue tongue- tie release. Given the increase in tongue-tie surgery, it is important to understand the perspectives of those choosing surgery. Third, we thank the JCPSLP editorial committee and contributors for putting together such valuable columns to reflect the theme of this issue. In “Viewpoints”, clinicians, educators and clients share their challenges and successes over the last year. Madeline Raatz has put together a great “Top 10” of tips and resources for being a responsive speech pathologist. In our “Resource review”, Rachel Higgins highlights a new tool for speech pathologists and other health care professionals to identify and support patients with communication difficulties. The “Around the journals” column for this issue looks at four publications reflecting on adaptive speech pathology services and whether we want to go “back to normal”. In “Ethical conversations”, Patricia Bradd and Trish Johnson consider our agility and responsiveness within an ethical framework.

46 Resource review

47 Around the journals – Andy Smidt

50 Ethical conversations: Speech pathology: An agile and responsive profession – Patricia Bradd and Trish Johnson

Enjoy reading Andy, Kat and Leigha

1

JCPSLP Volume 23, Number 1 2021

www.speechpathologyaustralia.org.au

Speech pathology: An agile and responsive profession

Speech-language pathologist practice changes in telehealth speech-language therapy for rural children Jessica Campbell, Deborah Theodoros, Trevor Russell, Nicole Hartley, and Nicole Gillespie

The purpose of this study was to understand practice changes made by speech-language pathologists and parents when shifting from in-person to telehealth delivery of paediatric speech-language therapy in a rural context. Participants in this qualitative exploratory study were two speech-language pathologists (SLPs), six managers, and 17 parents within BUSHkids, a not-for-profit organisation. Fieldnotes written during observations of in-person and telehealth therapy and clinician interview transcripts were analysed with an inductive thematic analysis approach. Two major practice change themes emerged from thematic analysis. These were extending parent roles (parents taking on a co-therapist role, including presenting therapy stimulus and instructions, delivering cues, supporting child posture, and judging speech accuracy), and preparing and adapting resources (clinicians creating or locating electronic stimuli or rewarding turn-taking games, and experiencing the lack of tactile cues in a telehealth modality). Telehealth with young children requires expanding parent roles to that of co-therapists. Increased support for clinicians and parents during the initial increased demands of telehealth practice could include providing ready-to-use electronic stimuli, explicitly discussing roles and responsibilities, and providing administrative support and telehealth room preparation. This study highlights the importance of understanding telehealth practice through the perspective of multiple stakeholders. R ural residents have less access to speech pathology compared to peers in major cities as only 3.9 percent of Australian speech-language pathologists (SLPs) are primarily employed in rural and remote areas

(Fairweather et al., 2016). Fewer practitioners means patients travel considerable distances for services and experience longer waiting times (Dew et al., 2013). At the same time, the Australian Early Development Census (AEDC) has found that a higher proportion of Australian children outside major cities are more developmentally vulnerable than their city-dwelling peers (Commonwealth of Australia, 2019). Employing telecommunications technology to enhance health care delivery and support (telehealth) is an important option for improving access to SLP services. In a systematic review of the efficacy of telehealth speech and language therapy in primary school-aged children (Wales et al., 2017), the authors found that there is some evidence to support the efficacy of telehealth approaches in such a population, although a limitation identified was the small sample size of most of the studies and overrepresentation of speech sound disorder therapy in the included studies. The highest level evidence identified by the authors were two randomised controlled trials (RCTs) for speech sound disorder therapy (Grogan-Johnson et al., 2013) and childhood apraxia of speech therapy (Parnandi et al., 2015). Non-RCT evidence has suggested the potential efficacy and acceptability of school-based speech-language therapy (Coufal et al., 2018; Gabel et al., 2013; Grogan-Johnson et al., 2010; Grogan-Johnson et al., 2011; Thomas et al., 2016; Wales et al., 2017). In school- based therapy, clear lines of communication with teachers and parents (Lincoln et al., 2014) and the use of therapy assistants and engaging children with their interests (Hines et al., 2015) have been reported as supportive factors. There are few studies that examine supportive factors for telehealth speech-language therapy in children younger than school-age. In a single qualitative study of play-based teletherapy with young children, SLPs found alternatives to children interacting with objects, such as interacting with the object on the client’s behalf (Ekberg et al., 2018). We have not identified other studies that have reported in a detailed way how clinicians adapt their practice to telehealth modalities with young children. It is known that parents are key stakeholders in the therapy of young children. Parents of children with developmental disabilities hold multiple specific expectations about therapy, including the likelihood of receiving a diagnosis, potential child achievements, service availability, therapist knowledge, skills, relationships and communications and parent’s own attendance and roles in therapy and home practice (Phoenix et al., 2020). Rather

THIS ARTICLE HAS BEEN PEER- REVIEWED KEYWORDS PAEDIATRIC RURAL SPEECH THERAPY TELEHEALTH VIRTUAL HEALTH

Jessica Campbell (top), Deborah Theodoros (centre) and Trevor Russell

2

JCPSLP Volume 23, Number 1 2021

Journal of Clinical Practice in Speech-Language Pathology

and processes involved. Both SLPs provided in-person and telehealth therapy weekly. Intervention BUSHkids implemented two telehealth service models by two different SLPs located at BUSHkids clinics. In the first model, children received therapy at a telehealth room in a community centre in a small town (population approximately 3,000). The telehealth computer had been previously provided by a local primary health network. In the second model, children received therapy in their homes which were more than 30 minutes’ drive from a rural service hub (population approximately 30,000) and used their own devices. The videoconference software was Zoom Meetings by Zoom Video Communications, Inc. (San Jose, California). Before beginning telehealth practice, the SLPs were trained in telehealth technology, and risk and distress management guidelines. Training was provided by the IT manager of BUSHkids and the first author of this study using training modules developed in consultation with BUSHkids clinical managers and reviewed by two members of the research team experienced with telehealth provision (DB, TR). Training covered how to use Zoom, strategies to maintain therapeutic alliance, strategies to identify alternatives to physical touch, and speech-language pathology telehealth guidelines and evidence. The SLPs also observed at least one telehealth therapy appointment by another clinician and completed one or more mock therapy appointments via Zoom with a colleague. A total of 70 telehealth therapy appointments were conducted during the data collection period (mean 7.77 per client, range 4–10). In-person participants were also observed and interviewed to compare in-person and telehealth practice. In-person participants were recruited from the in-person clinic caseload of the two SLPs during the same period as telehealth provision. A total of 68 in- person sessions were conducted (mean 9.71 per client, range 8–10). Participants Participants included two BUSHkids SLPS, six BUSHkids managers and 17 parents of child clients. The two SLPs were aged 18–29, female, with 1–2 years in their profession. Both had heard of telehealth but had no experience with it. The six manager participants were a clinical supervisor, line manager, IT manager, clinical manager, and two executive leaders (three males, three females, aged 30–44 (n = 3) or 45–50 (n = 3). Three were experienced with telehealth and three had no experience with it. Telehealth participants included nine parents, most of whom were aged 30–44 (89%) and women (89%). These parents were the parents of nine child clients (mean age 4.7 years, range 3–6 years, five boys and four girls). Three families received therapy at the community centre and six received telehealth in their home. In-person participants included eight parents (six aged 30–44, two aged 18–29, seven women, one man), who were the parents of eight children (mean age 5.1 years, range 3–7 years, four boys and four girls). Recruitment A list of two SLPs able to take on telehealth clients in addition to their current caseloads were provided by BUSHkids. SLPs were provided with detailed verbal and written information about the research by the first author via email and phone. They were assured that their participation

than being passive consumers of therapy, parents can take active and effective roles in therapy. A Cochrane systematic review of the effectiveness of speech-language therapy for children with primary speech and language delay/ disorder found no significant difference between clinician- implemented and parent-implemented intervention when parents were trained to deliver the intervention (Law et al., 2003). Parents are known to take on a co-therapist role when doing home speech-sound practice with children (Sugden et al., 2019) and can provide high dosage speech and language home programs when they receive direct training (Tosh et al., 2017). Other systematic reviews have found preliminary evidence for parent-mediated interventions. Parent-mediated intervention training may increase parent knowledge, intervention fidelity, and improve social behaviour and communication skills for children with ASD, although a low number of RCTs and other limitations limited the generalisability of the findings (Parsons et al., 2017). Parent-implemented interventions for late talkers are potentially more effective that clinician- directed therapy, although generalisability is limited by variations in parent training procedures and unclear ecological validity of parent training (Deveney et al., 2017). Given the importance of parents in these therapy approaches, it is likely that parents will also be key stakeholders in telehealth speech-language therapy. Despite this, the roles of clinicians and parents in such therapy are as of yet not clearly described in extant literature. In summary, while there is evidence for the efficacy of telehealth speech-language therapy and parents are likely to be key stakeholders in such therapy, there is, as yet, limited understanding of clinician and parent practice changes and other supportive factors needed for telehealth adoption. This study aimed to explore clinician and parent practice changes involved in implementing telehealth SLP therapy in an existing service for rural children. Methods Setting This research was conducted at BUSHkids, a not-for-profit organisation providing free allied health and education services to rural families in Queensland, Australia. BUSHkids funded the first author’s PhD scholarship and provided funding for transcription. Ethical approval was obtained from the University of Queensland Human Research Ethics Committee B (2017001829). Approach A pragmatist paradigm was used with the intention to create knowledge that could be practically applied in daily clinical work. A qualitative exploratory case study design was used. Case study design is appropriate when describing a case bounded by time or place that can inform a problem (Creswell et al., 2007). This case study examined the key activities of speech-language therapy conducted in-person and via telehealth by two BUSHkids SLPs. Telehealth was a new service for BUSHkids. The case was bound by time (the first six months of telehealth (TH) provision 2 May 2018 March – 1 January 2019) and place (services provided from BUSHkids Emerald and Mount Isa clinics). Telehealth and in-person speech-language therapy were examined using two data sources: (a) observations of SLPs and families during telehealth and in-person therapy; (b) interviews with SLPs about their experience of therapy

Nicole Hartley (top) and Nicole Gillespie

3

JCPSLP Volume 23, Number 1 2021

www.speechpathologyaustralia.org.au

was voluntary and would not affect their employment with BUSHkids before being invited to take part in the research. A list of managers who directly or indirectly supervised the SLPs (clinical supervisor, line manager, clinical area manager, and executive managers) was provided by BUSHkids. The IT manager was also included in recruitment given their involvement in telehealth technology training and support. All managers were provided with detailed verbal and written information about the research by the first author, in person, via email and/or phone. They were assured that their participation was voluntary and would not affect their employment with BUSHkids before being invited to take part in the research. All child clients had been identified by BUSHkids for unidisciplinary SLP care and were on the waiting list for the two SLPs. This meant that they had met the BUSHkids eligibility criteria of being aged birth to end grade 1 (approximately age 6), not receiving individual speech-language services elsewhere, and referred for mild-moderate concerns with fluency, language, speech, voice or multi-modal communication, excluding severe presentations and feeding and swallowing concerns. In addition, to be eligible for research, the SLP judged that parent and child were able to attend to therapy, were medically stable, and had carers over 18 without severe health condition impairing capacity to consent to research. SLPs contacted parents via phone to offer either in-person or telehealth service. Families residing in the same town as the BUSHkids clinic were offered in-person service. Families residing outside town were offered the telehealth service. Three families declined the offer of the telehealth service, compared to nil families declining the offer of in-person services, raising the possibility that parent attitudes to telehealth affected uptake. Research participation was discussed at the end of the first therapy session. Treating SLPs provided eligible clients with detailed verbal and written information about the research. Parents were assured that participation would not impact on their service with BUSHkids. If parents declined research participation they continued to receive the therapy, but no data was collected. One telehealth family declined research participation, with no reason given. No in-person All data was collected by the first author, an SLP and PhD student but not a treating SLP in this study. In-person therapy was observed before the SLPs started telehealth. Telehealth therapy was observed at three time points to determine whether SLP and parent practice changed over time (day 1–2, day 6–7, and day 12–13). The researcher took detailed observation fieldnotes using a form to guide which included sections about the people involved and their roles, processes and practices happening throughout the session, and objects used in the session. Ten in-person observations (mean length 48 minutes, range 32–63) and 12 telehealth observations (mean length 42 minutes, range 19–62) were conducted. To reduce the burden on each family, each family was observed once only. SLPs were also interviewed in their offices prior to telehealth delivery, after each observation, and after six months of telehealth delivery. An open-ended interview guide was used to explore SLPs experiences of delivering telehealth. Eight interviews were conducted (mean 41 minutes, range 23–77). Managers were interviewed in their offices six months after telehealth began to understand families declined research participation. Data collection and analysis

changes made by the organisation to implement telehealth (n = 6, mean 57 minutes, range 42–86). All interviews were conducted using interview guides developed by the authors and were recorded and transcribed verbatim. To identify key themes in the case, an adapted inductive thematic analysis method was used (Braun & Clarke, 2006). The first author read and re-read transcripts and observation fieldnotes and noted initial impressions. She developed a coding protocol which was discussed with the remaining authors and feedback given to improve the reliability of coding. The coding protocol was composed of practices across four domains (scenes and actions, people, processes, objects) (domains adapted from Emerson et al., 2011), with telehealth and in-person data coded separately under each domain. Author NH checked raw data was coded to appropriate codes and reassigned data in discussion with the first author. All other authors then refined the coding protocol and coding process. The first author then identified and mapped themes that described important focal points for differences in practice between telehealth and in-person. Further discussion took place with the remaining authors to refine the themes. A report of themes and exemplars was produced and this was edited until consensus was reached among all authors. Results Two major themes emerged from thematic analysis of the interview transcripts and observation fieldnotes: extending parent roles and preparing and adapting resources . See Table 1 for further explication of these themes and associated extracts. Theme 1: Extending parent roles A major theme that was revealed was that parents’ roles shifted from an observer role in-person to a co-therapist role via telehealth, although this shift was not a complete transition in all families. In in-person therapy, parents observed therapy and occasionally verbally encouraged children to complete a therapy task: In-person observation fieldnote: [Child has a cat toy]. Clinician: “Now put him under the table”. The child gets it wrong. Dad says “under the table”. (In-person Family 2, C2). In contrast, in telehealth therapy parents presented stimulus and task instructions to children, delivered physical, gestural, and verbal cues, supported the child’s posture and judged whether children were producing speech sounds accurately: Telehealth observation fieldnote: Mum is asking child if he hears a short sound, or a long sound (sound discrimination). Mum places the flash cards on the visual aide ... Mum does a big swing with the child [in her arms] for “long sound” making him giggle. Modelling the sound into his ear three times while making him laugh. (Telehealth Family 1, C1) Telehealth observation fieldnote: “I wish I had lots of fish in my fish tank” (As the boy is talking and says “wish” and “fish”, [target sound “sh”]) I can see Mum nodding, then the clinician nods back, they appear to have established a partnership where Mum shares non-verbally information about correct productions. (Telehealth Family 8, C2) However, not all parents took on these aspects of the therapist role (presenting stimuli and instructions, cues, supporting posture, and judging speech sound accuracy)

4

JCPSLP Volume 23, Number 1 2021

Journal of Clinical Practice in Speech-Language Pathology

during telehealth delivery. SLPs reported in interviews that some parents did household chores while their child was having therapy (C2) and that a child left the therapy room while the parent stayed behind with a younger sibling, and the child had to be returned to the room by the community centre receptionist (C1). A manager reported that both SLPs were concerned about parent roles in therapy: “[Clinicians] often will talk through how they need to make sure parents are in the room during therapy. That’s a big drama ... We need to set out the expectations a little bit more with that” (M1). This manager felt that role discussion should take place when a telehealth service was being offered and reinforced in a service welcome letter. The SLPs had mixed feelings about the impact of the parent-led approach. One SLP felt that that greater parental control meant greater generalisation of therapy into the home environment: “I found a lot of the parents actually reported better outcomes because they were doing more at home, because they were more the coach at home” (C1). In contrast, the other SLP felt that the child completed fewer practices and worked on fewer goals within each therapy session, as the clinician wasn’t as able to “drive” therapy as in in-person practice: ... you have to change to suit the family, which you do in session as well, but when it’s you with them [in-person] it’s a bit different, because you maybe get more out of them, or drive them a little more. (C2) One SLP and one manager commented that parental role extension had limits to it and would not be appropriate for children with severe behavioural or sensory concerns (C1, M1). Theme 2: Preparing and adapting resources A second major theme that emerged was that telehealth therapy involved additional parent and clinician processes centred around finding virtual substitutes for tangible objects or physical (tactile) cues. In in-person therapy, SLPs collected physical board games, stimuli cards, and craft materials from the clinic library before therapy, and used them to engage children in therapy sessions: In-person observation fieldnote: Clinician: “I have some new pictures [therapy stimuli] to draw on today and some new pens. Which colour would you like?” Child is very excited and says “yay” when she sees the pictures and pens. (In-person Family 2, C2). In contrast, in telehealth delivery, both SLPs reported they needed extra time to figure out “what will work on a screen” and prepare new electronic resources. Examples of electronic resources developed included a Microsoft Word ® bingo game with speech sound targets and a rewarding PowerPoint ® that revealed a picture when clicked by the child (C1, C2). In addition to these virtual substitutes, both SLPs also reported and were observed to send families physical objects. For home telehealth, the SLP posted a resource pack to clients for the entire therapy block. The SLP working with the community centre emailed the receptionists resources for printing on the day of therapy and also dropped a box of objects at the community centre prior to beginning telehealth delivery. The objects provided by the SLPs included Lego ® , Play-doh, mini- skateboards, stamps, and board games. Children enjoyed the compensatory concrete objects: In-person observation fieldnote: Child puts the Play-doh on the screen. Clinician:

“Wow, how do I look? What did you put on me?” Child is laughing a lot (C2). One parent of a 4-year-old boy reported that her child enjoyed both the physical game that was in the box at the child’s location (pop-up pirate) and a virtual game (reveal the picture): He loves the Pop-Up Pirate game. So if he does his sound then he gets to put the sword in. He really enjoys that ... And he enjoys ... there’s a game ... It’s a covered picture on the computer screen and then every time he does the sound he gets to take a puzzle piece away to reveal the picture. He loves that one as well. (PT1, Telehealth) Some difficulties were reported with providing physical objects. The home telehealth SLP reported that despite posting physical objects to families for the child to sort during semantic therapy, it was difficult to control the flow of therapy when the clinician couldn’t manipulate objects at the same time as the child: I didn’t have any control of the game so we actually weren’t getting any of the actual learning we wanted. So, I finally worked out with her ... I controlled it, but to make it into a competition, and then she would just race me, and then she was like, bang, bang, bang, I got so many productions ... from her. (C2) She also reported that despite posting resources to parents, parents sometimes did not have time to prepare the resources, e.g. cut-up flashcards. This process of preparing virtual and physical alternatives required “a bit more brain power and creativity” (C1) and was associated with more clinician anxiety than in in-person practice. Manager 1 stated: “I also know the anxiety ... with both of them [SLPs] was much higher than it would have been since starting a normal therapy block. So that’s something that people need to be aware of.” On the other hand, two managers felt that telehealth practice resulted in a higher quality service than in-person as clinicians were required to develop their skills in service planning, organisation, and resource development (M1, M2): [The quality of service] is probably even higher because of the level of preparedness you need to go into, in terms of not having things at your fingertips. So, really thinking hard. If this doesn’t work, I have got this as my backup. (M2) The IT manager also felt that the SLP telehealth preparation should extend to the preparation of telehealth rooms, after he noted a clinician conducted telehealth from a cluttered room: “there was ... one of those little gym trampolines there in the background, flipped up on its side ... So, it wasn’t an inviting environment” (M3). Managers predicted clinicians would reach a point where preparation and adaptation became effortless (M2, M1), although this had not happened by close of data collection (6 months). Participants commented that telehealth preparation could be reduced with administrative support (M1) and use of a PDF splitter to easily manage digital files (C2). However, this increased preparation time was perceived as a trade-off against the reduced travel time in telehealth (M1). A final aspect of resource preparation that emerged in this theme was that clinicians were not adequately equipped to find alternatives to physical prompts. Physical prompts, such as tactile speech sound cues for in- person sessions (e.g., touching the child’s throat to elicit a /k/ phoneme in articulation therapy) were observed.

5

JCPSLP Volume 23, Number 1 2021

www.speechpathologyaustralia.org.au

Table 1. Practice change themes and exemplars Theme and description

Exemplars (observation data in italics)

Theme 1: Extending parent roles Telehealth practice required parents to take on a co- therapist role. This involved judging the accuracy of speech sound productions, as well as setting up the telehealth device and providing therapy activities. This was necessary as therapists were sometimes not able to judge productions due to difficulty with seeing child’s mouths as children moved around. SLPs reported they needed to clarify roles with parents. One SLP reported a child leaving the room during therapy. One SLP perceived that less control over therapy meant that the child completed fewer practices and worked on fewer goals. This role extension was not perceived to be appropriate for children with severe behavioural or sensory concerns. Theme 2: Preparing and adapting resources Telehealth therapy involved additional work processes centred around finding virtual substitutes for tangible objects. This increased SLP preparation time. Adaptations observed were identifying resources to elicit responses in therapy and identifying which TH games worked well for different clients. Other preparation involved preparing the telehealth room. Additional preparation was associated with additional anxiety for SLPs. Tactile cues are also part of IP practice. No SLPs were observed to compensate for the lack of tactile cues, although one SLP reflected on missed opportunities to encourage parents to use physical objects.

[Child has a cat toy]. Clinician: “Now put him under the table”. The child gets it wrong. Dad says “under the table”. (IP Obs 2, C2) Mum is asking child if he hears a short sound, or a long sound (sound discrimination). The mother places the flash cards on the visual aide ... Mum does a big swing with the child [in her arms] for “long sound” making him laugh and giggle. Modelling the sound into his ear three times while making him laugh. (TH Obs 1, C1 ) “I found a lot of the parents actually reported better outcomes because they were doing more at home, because they were more the coach at home.” (C2) “You focus so carefully on their mouths, ... when you see them in person, and you can’t really do that with the camera. ... you can’t stare at them as much” (C2) “I wish I had lots of fish in my fish tank” (As the boy is talking and says “wish” and “fish), [target sound “sh”] I can see mum nodding, then the clinician nods back, they appear to have established a partnership where Mum shares non-verbally information about correct productions. (TH Obs 1, C2) “... about yesterday’s client who did a runner ... after talking to M1 I’ve just ordered a temporary plastic door lock to be send to the community centre. I’ll talk to F about giving it to the mum so that the mum can lock the door herself from the inside.” (email correspondence, C1) Child: “The girl is cooping”. SLP: “The girls is cooking. You said cooping. It’s cooking”. Child: “That’s what I said!” SLP: “Maybe you did, maybe I couldn’t hear you”. (TH Obs 4, C2) “[Child’s] pretty good, because when Mum’s actually away a bit, she concentrates better, so Mum’s always like, “I’m here, I’m listening. I’m just in the background.” (C2) “... you have to change to suit the family, which you do in session as well, but when it’s you with them [in person] it’s a bit different, because you maybe get more out of them, or drive them a little more.” (C2) “... the only client that I’m thinking of that would be really difficult to deal with, with be severe disability. Severe ASD, where it’s really—or it’s really challenging behaviour or really hard to get any compliance.” (M1) “...the [preparation] time has gotten less for the telehealth kids ... because the types of activities we’re doing, I’ve just realised what works so I’ve continued to do the same types of activities with them.... that takes quite a bit of time for the in-person [therapy] as well but I think ... it’s more figuring out what will work on a screen ...” (C1) “It still takes probably a bit longer to prep for than in-person clients ... a bit more brain power and creativity probably.” (C1) “Checking in [with parents] as to, “What kind of cause/effect games or toys do you have? What sorts of ballgames do you play as a family? ... Have you got colouring in pencils...so that will then help us determine; do we send a pack out for the family to use at their end? ... working with the parent to work out would the child benefit from a snack before “... because if they are at home, it is very easy to leave the desk or the table and go raid the fridge or the pantry.” (M2) “... I also know the anxiety ... with both of them [SLPs] was much higher than it would have been since starting a normal therapy block.So that’s something that people need to be aware of.” (M1) “[The quality of service] is probably even higher because of the level of preparedness you need to go into, in terms of not having things at your fingertips. So, really thinking hard. If this doesn’t work, I have got this as my backup.” (M2) “There was no BUSHkids logos, there was ... one of those little gym trampolines there in the background, flipped up on its side ... So, it wasn’t an inviting environment.” (M3) SLP: “I have some new pictures [therapy activities] to draw on today and some new pens. Which colour would you like?” Child is very excited and says “yay” when she sees the pictures and pens. (IP Obs 2, C2) “I probably spent more time getting to know the kids in these telehealth sessions, more about what their favourite things were. Whereas kids here [in the clinic], you just have the games, and you’re kind of like, “Well, this is what we’re playing.” (C2) “I didn’t have any control of the game so we actually weren’t getting any of the actual learning we wanted. So, I finally worked out with her ... I controlled it, but to make it into a competition, and then she would just race me, and then she was like, bang, bang, bang, I got so many productions ... from her.” (C2) “... I’d keep saying smile, but normally I would literally just ... poke my fingers towards her or actually, you know, touch their cheeks ... or even ... kids with a lisp, I would try and ... get them to hold something between their teeth over and over again... I guess you could get the parents to bring them and make sure they’ve got all that stuff ready.” (C2) “There’s not really much—so apart from physical, hands-on prompting that you can’t do over telehealth, there’s not really much you can’t do. So I don’t think there’s any difference in whether—in meeting client need”. (M2) “He loves the Pop-Up Pirate game. So if he does his sound then he gets to put the sword in. He really enjoys that ... And he enjoys ... there’s a game ... It’s a covered picture on the computer screen and then everytime he does the sound he gets to take a puzzle piece away to reveal the picture. He loves that one as well.” (TH P1) Child puts the Play-doh on the screen. Clinician: “Wow, how do I look? What did you put on me?” Child is laughing a lot . (IP Obs, C2)

C = Clinician, M = Manager, P = Parent, IP = in-person; TH = telehealth; Obs = observation

6

JCPSLP Volume 23, Number 1 2021

Journal of Clinical Practice in Speech-Language Pathology

In telehealth practice, SLP C2 reported that when her attempts to instruct the parent to give tactile prompts were not successful, she altered her therapy plan to work on other sounds. She also reflected that she had missed opportunities to ask parents to have physical objects such as straws available as compensation for tactile cueing: I’d keep saying smile [via telehealth], but normally [in- person] I would literally just ... poke my fingers towards her or actually, you know, touch their cheeks ... or even ... kids with a lisp, I would try and ... get them to hold something between their teeth over and over again ... I guess you could get the parents to bring them and make sure they’ve got all that stuff ready. (C2) A manager commented that she felt the lack of tactile prompting was one of the few areas of clinical practice not available to staff via telehealth: “apart from physical, hands- on prompting that you can’t do over telehealth, there’s not really much you can’t do. So I don’t think there’s any difference ... in meeting client need” (M2). Discussion This study aimed to understand key practice changes made by SLPs and parents when shifting from in-person to telehealth therapy. Parents in the telehealth modality were required to take on a co-therapist role. Clinicians also adapted their practice in key ways—for example, they prepared virtual alternatives to previously physical therapy resources, and provided physical objects for the child via post or in a box left at the partner venue.The only aspect that clinicians were not able to implement via telehealth was hands-on tactile cueing for speech sound therapy. Our findings suggested that not all parents were aware of their new role as co-therapist. This is a similar finding to a study exploring parent experience of home speech- sound practice with children in which responsibilities were not always made clear to parents (Sugden et al., 2019). Explicitly discussing clinician and parent responsibilities is particularly important as parents have a wide variety of expectations about roles they will take in therapy (Phoenix et al., 2020) and because parent-delivered therapy can be uncomfortable for parents (Thomas et al., 2016). As direct parent training is a facilitating factor for effective home speech and language programs (Tosh et al., 2017), direct parent training should also be considered as a potential facilitating factor for telehealth. Moreover, wholly parent-focused therapy approaches should be considered by telehealth clinicians, given the strong evidence for parent-led in-person speech-language therapy approaches (Deveney et al., 2017; Law et al.; Tosh et al., 2017). Parent- centred telehealth also has other potential benefits such as empowering parents to better support the development of their child’s communication skills and allowing opportunities for therapy strategies to transfer into everyday routines (Snodgrass et al., 2017). Telehealth-based parent-mediated developmental-behavioural intervention for preschool children with autism spectrum disorder has been trialled with high parent satisfaction in both self-directed and therapist-assisted formats (Ingersoll & Berger, 2015). Similar trials in speech sound disorder and language therapy would assist telehealth clinicians to understand barriers and facilitators to parent-led approaches via telehealth. The additional preparation and adaptation required in telehealth suggests that initially telehealth practice is likely to be more effortful for clinicians than in-person practice.

This is supported by Lincoln and colleagues’ findings that clinicians felt developing resources for telehealth was stressful, requiring creativity and adaptability (Lincoln et al., 2014). The limited timeframe of this study and the recruitment of only early career SLPs inexperienced with telehealth inhibited a deeper understanding of clinician effort. Future research should consider whether career stage, previous telehealth experience and whether looking at telehealth adoption over periods greater than 6 months influences perceived clinician effort. The importance of physical objects identified in this study is supported by other literature. For instance, Ekberg and colleagues described how clinicians were unable to provide physical objects as rewards in play-based therapy (Ekberg et al., 2018). However, they also found that this was helpful for clinicians as it prevented clients from easily accessing rewarding objects without producing a target utterance (Ekberg et al., 2018). In our study, SLPs were able to provide a range of non-physical rewards that appeared to be enjoyed by children, such as web browser and PowerPoint games. However, workarounds for the lack of physical cues were not successfully identified by clinicians. Further research could investigate the feasibility of tactile cues completed by trained assistants or parents and clinicians could be explicitly trained in alternatives, such as having parents provide objects such as straws to elicit speech sounds. Other limitations of our study include that members were not asked to read a summary of results due to the time constraints of the study. In addition, this study may not be transferable to children outside the age range in this study (3–7 years). Clinical implications In this study speech-language therapy was successfully provided to rural families both in the home and in a community centre location where no other speech- language therapy was available. Important clinical findings of this study are that SLPs should be trained to explicitly discuss the co-therapist role with parents when offering telehealth services, and explain how parents can present instructions and stimuli, deliver cues, support child posture, and judge child accuracy, as well as troubleshoot devices and motivate children. SLPs should discuss roles and responsibilities for preparation and manipulation of resources with parents. Employing structured parent-led therapy programs may assist clinicians and parents with understanding their roles as well as aligning with evidence- based practice. Identification and effectiveness research of ready-to-use electronic stimuli, such as images or a game with virtual “objects” for semantic therapy, would benefit SLPs. Managers should acknowledge and normalise SLP experiences of anxiety and increased initial effort in telehealth practice and provide additional administrative support where possible. Conclusion This study explored practice changes required when shifting from in-person to telehealth speech-language therapy with rural children. Findings indicated there were changes in roles for parents and clinicians during telehealth sessions: parents took on more of a therapist role and clinicians spent more time preparing for therapy and adapting therapy materials. Although clinicians provided compensatory physical objects to clients or created virtual

7

JCPSLP Volume 23, Number 1 2021

www.speechpathologyaustralia.org.au

substitutes, they did not successfully navigate the challenges of identifying alternatives for hands-on tactile cues, suggesting further training in this area would support telehealth practice. Facilitators to successful telehealth included administrative support for clinicians and more explicit discussion with parents or direct training relating to their co-therapist role. Managers acknowledged increased clinician anxiety related to telehealth practice and the need for additional administrative support for clinicians, as well as the importance of preparing telehealth rooms. The COVID-19 pandemic has required many clinicians to rapidly expand telehealth practice with young children. This study underlines the value of exploring telehealth practice changes to identify how clinicians can better respond to telehealth practice. Acknowledgements BUSHkids provided the setting, clinicians and equipment for this research and proposed the telehealth models to be trialled. BUSHkids sponsored the first author’s PhD scholarship and provided funds for transcription. The authors have no conflict of interest to declare. They take complete responsibility for the integrity of the data and accuracy of data analysis. References Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology , 3 (2), 77–101. https://doi.org/10.1191/1478088706qp063oa Commonwealth of Australia. (2019). Australian Early Development Census National Report 2018: A snapshot of early childhood development in Australia . https://www. aedc.gov.au/resources/detail/2018-aedc-national-report Coufal, K., Parham, D., Jakubowitz, M., Howell, C., & Reyes, J. (2018). Comparing traditional service delivery and telepractice for speech sound production using a functional outcome measure. American Journal of Speech-Language Pathology , 27 (1), 82–90. https://doi.org/10.1044/2017_ AJSLP-16-0070 Creswell, J. W., Hanson, W. E., Clark Plano, V. L., & Morales, A. (2007). Qualitative Research Designs: Selection and Implementation. The Counseling Psychologist , 35 (2), 236-264. https://doi.org/10.1177/0011000006287390 Deveney, S. L., Hagaman, J. L., & Bjornsen, A. L. (2017). Parent-implemented versus clinician-directed interventions for late-talking toddlers: A systematic review of the literature. Communication Disorders Quarterly , 39 (1), 293–302. https://doi.org/10.1177/1525740117705116 Dew, A., Bulkeley, K., Veitch, C., Bundy, A., Gallego, G., Lincoln, M., Brentnell, J., Griffiths, S. (2013). Addressing the barriers to accessing therapy services in rural and remote areas. Disability and Rehabilitation , 35 (18), 1564–1570. https://doi.org/10.3109/09638288.2012.720346 Ekberg, S., Danby, S., Theobald, M., Fisher, B., & Wyeth, P. (2018). Using physical objects with young children in “face-to-face” and telehealth speech and language therapy. Disability and Rehabilitation , 41 (14), 1–12. https://doi.org/ 10.1080/09638288.2018.1448464 Emerson, R. M., Fretz, R. I., & Shaw, L. L. (2011). Writing ethnographic fieldnotes. University of Chicago Press. https://doi.org/10.7208/ chicago/9780226206851.001.0001 Fairweather, G. C., Lincoln, M., & Ramsden, R. (2016). Speech-language pathology teletherapy in rural and remote educational settings: Decreasing service inequities. International

Journal of Speech-Language Pathology , 18 (6), 592–602. https://doi.org/10.3109/17549507.2016.1143973 Gabel, R., Grogan-Johnson, S., Alvares, R., Bechstein, L., & Taylor, J. (2013). A field study of telepractice for school intervention using the ASHA NOMS K-12 database. Communication Disorders Quarterly , 35 (1), 44–53. https:// doi.org/10.1177/1525740113503035 Grogan-Johnson, S., Alvares, R., Rowan, L., & Creaghead, N. (2010). A pilot study comparing the effectiveness of speech language therapy provided by telemedicine with conventional on-site therapy. Journal of Telemedicine and Telecare , 16 (3), 134–139. https://doi. org/10.1258/jtt.2009.090608 Grogan-Johnson, S., Gabel, R. M., Taylor, J., Rowan, L. E., Alvares, R., & Schenker, J. (2011). A pilot exploration of speech sound disorder intervention delivered by telehealth to school-age children. International Journal of Telerehabilitation , 3 (1), 31–42. https://doi.org/10.5195/ ijt.2011.6064 Grogan-Johnson, S., Schmidt, A. M., Schenker, J., Alvares, R., Rowan, L. E., & Taylor, J. (2013). A comparison of speech sound intervention delivered by telepractice and side-by-side service delivery models. Communication Disorders Quarterly , 34 (4), 210–220. https://doi. org/10.1177/1525740113484965 Hines, M., Lincoln, M., Ramsden, R., Martinovich, J., & Fairweather, C. (2015). Speech pathologists’ perspectives on transitioning to telepractice: What factors promote acceptance?. Journal of Telemedicine and Telecare , 21 (8), 469–473. https://doi.org/10.1177/1357633x15604555 Ingersoll, B., & Berger, N. I. (2015). Parent engagement with a telehealth-based parent-mediated intervention program for children with autism spectrum disorders: Predictors of program use and parent outcomes. Journal of Medical Internet Research , 17 (10), e227. https://doi. org/10.2196/jmir.4913 Law, J., Garrett, Z., Nye, C., & Law, J. (2003). Speech and language therapy interventions for children with primary speech and language delay or disorder. Cochrane Database of Systematic Reviews , (3) https://doi. org/10.1002/14651858.cd004110 Lincoln, M., Hines, M., Fairweather, C., Ramsden, R., & Martinovich, J. (2014). Multiple stakeholder perspectives on teletherapy delivery of speech pathology services in rural schools: A preliminary, qualitative investigation. International Journal of Telerehabilitation , 6 (2), 65–74. https://doi. org/10.1177/1357633x15604555 Parnandi, A., Karappa, V., Lan, T., Shahin, M., McKechnie, J., Ballard, K., Ahmed, B., & Gutierrez- Osuna, R. (2015). Development of a remote therapy tool for childhood apraxia of speech. ACM Transactions on Accessible Computing (TACCESS) , 7 (3), 1–23. https://doi. org/10.1145/2776895 Parsons, D., Cordier, R., Vaz, S., & Lee, H. C. (2017). Parent-mediated intervention training delivered remotely for children with autism spectrum disorder living outside of urban areas: Systematic review. Journal of Medical Internet Research , 19 (8), e198–e198. https://doi.org/10.2196/ jmir.6651 Phoenix, M., Smart, E., & King, G. (2020). “I didn’t know what to expect”: Describing parents’ expectations in children’s rehabilitation services. Physical & Occupational Therapy In Pediatrics , 40 (3), 311–329. https://doi.org/10. 1080/01942638.2019.1665155

8

JCPSLP Volume 23, Number 1 2021

Journal of Clinical Practice in Speech-Language Pathology