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Meeting with Speech Language Pathologist (SLP) for young children from Ontario.

Background information

• Working for a network of clinics that transitioned to 100% virtual practice due to COVID-19.

Adopting online practice

• Clinicians at the office were not practicing during a period where partnered organization was evaluating online meeting technology for network / software, and storage security.
• Parents were initially skeptical of online therapy - how can it be effective without being in-person?
  • The challenge is the speech-sound production
    • Whether or not their pronunciation is good
    • Depends on the child to sit and face the microphone
  • Otherwise assessments can be done well online
• Real benefit from having clients and family in home setting
  • It's comfortable and doesn't need to adjust to a different clinic setting
  • Clinics can have negative associations, so home environment is beneficial
  • Logistics much easier and services more accessible. Parents did not have to travel or pick their children up from daycare etc.
• Affect on outcomes:
  • If parent is able to manage the remote relationship and takes to coaching well - the child makes a lot of progress
  • If parents do well, the child does well - true online and in person
• How do children react to online visits?
  • Kids are mostly used to it - but some children as still shy
  • Turning off camera can sometimes help - which is something that isn't available in real life.
• body language, play skills, and voice quality are easily assessed online, however there are other challenges with the technology (see below)
• initially parents were refusing online and hoping for in-person, but as pandemic dragged on, many have opted for online
  • over time trust is built and less skepticism about online therapy
  • some clients still opt for phone
  • some clients refuse online all-together - and there may be many reasons for this decision
  • some clients still prefer in-person as they were doing in-person visits before going online
• Virtual care is likely going to stay as a service option and parents given a choice
  • Assessments done in-person but follow-ups done online
• For remote communities online therapy has been an option for a while (even before pandemic)
• Motor speech / feeding / swallowing therapy still requires in-person consultation - can't be done online.
• Many families are younger and comfortable with technology

Online platform

• Currently using Go2Meeting, but will be transitioning to Zoom Health in the next month.
• Zoom Health will facilitate going webinar style group meetings like workshops and group consultations
• Booking done through phone and sometimes email
  • Was evaluating / piloting a booking platform called "Care Dove" before pandemic, but that was put on hold since then.
• Sometimes families request other technology, but can only use the software that has been approved.

Technical challenges

• Network connectivity is a big problem - audio or video can degrade or cut out
• Children move around and not always face the microphone or move away from the microphone
  • this makes it challenging for therapist to hear clearly, especially during assessments
• Speech and sound production is important in therapy, but quality of pronunciation and articulation can be tricky over microphone and online.
• Parents are using a variety of devices:
  • laptops - nice and stable, but not mobile
  • phones or tablets - more mobile, but hard to position and prop-up
• Dealing with technical challenges
  • look for ways to take bandwidth off internet - like switching to telephone for voice and Go to Meeting for video
  • sometimes have to fall back to phone completely

• Hard for parents to position camera for both child and parent to be in the same frame for play therapy
• Can also be hard to follow a moving child with a device, especially a laptop
• Sometimes can't see what child is pointing to if important parts are out of the frame - requires the parent to interpret and troubleshoot for the therapist
• Some parents will use multiple devices - one to follow the child, and the other in a fixed location for different angles
• For formal language test tools, therapist shares screen of test pictures, child points to answer on screen, this requires the parent to relay the answer to the therapist, or use second camera to show child screen activity 
• Multiple family members are competing for household internet and network

Other challenges

• Parents face other challenges
  • staying organized and keeping appointments
  • saving the link and password - sometimes emails are deleted, put into spam etc.
• English may not be first language - especially hard when troubleshooting technical issues
  • However, parents seem to manage okay with instruction sheets sent in English ahead of time
• Providing informed consent takes a lot of time and therapists find it's easier if they do it one-on-one with parents instead of asking admins who have limited time.

Partnering with parents

• Equip and empower parents to be effective therapists
• Best outcomes have come from situations where parents are engaged and active in children's therapy
• Screen separation changes the dynamics - forces parents to be the hands of the therapist
  • Therapist becomes the coach and parents are empowered
  • Parents more connected in therapy rather than a passive observer
  • Parents can use whatever is in their homes - comfortable and familiar.

Transition to online therapy

• Colleagues helped a lot with sharing knowledge and practices
• Attended a lot of webinars
• Weekly check-ins with colleagues
• The U.S. has a lot more research and practice in online speech language therapy
  • many diagnostics were adopted from US practice

Privacy

Privacy can be an issue

• Other family members can join in
• Lots of distractions and disruptions, background noise, etc.
• Hard to control - affects client's experience
• Sometimes home isn't big enough to have a secluded place

Transitioning clients

• There is no persistent record like in medical health.
• A report is written and given to the parent.
• Copies are sometimes given to a school to transition the client early (schools apply for funding early so reports may be sent before student is expected to attend)