JCPSLP Vol 23, Issue 1 2021

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