JCPSLP Vol 23, Issue 1 2021

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

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JCPSLP Volume 23, Number 1 2021

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