JCPSLP Vol 23, Issue 1 2021

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