Caso de las Comunidades Afrodescendientes Desplazadas de la Cuenca del Río

The mode of telepractice presents an increased opportunity for SLTs to engage in the cross-cultural delivery of ECI. Therefore, the discussed cultural considerations of family-SLT and family-child practices are particularly important to consider within this context. As a potential ECI service delivery option, telepractice emerged in direct response to a need to provide services to remote populations (Houston, Stredler-Brown, & Alverson, 2012). Research began over 50 years ago but has only recently undergone

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significant expansion (Speech Pathology Australia, 2014). Telepractice has been used with clients across the entire age range, for the purposes of screening, assessing, treating, following up and consulting (American Speech-Language-Hearing Association, 2014). Emerging research has identified telepractice to be generally effective in providing services in the areas of fluency, aphasia, dysarthria, voice disorders, apraxia, dysphagia, and general paediatric speech and language disorders (Edwards, Stredler-Brown, & Houston, 2012). This wide application of telepractice was echoed by the survey response of SLTs who delivered services through telepractice (American Speech-Language-Hearing Association, 2014). However, a call remains for further research, particularly around telepractice treatment outcomes (Houston, 2014).

2.8.1 Telepractice in early intervention.

Due to the nascent nature of telepractice, this section discusses the outcomes of early intervention (EI) studies, which encompass SLTs as well as other interventionists working in EI, such as physiotherapists (PT) and occupational therapists (OT). The physical distance in telepractice generates the ideal set of circumstances for the delivery of EI (Olsen, Fiechtl, & Rule, 2012). As the interventionist is not face-to-face with families and their children, a strong collaborative partnership is crucial to share knowledge and skills. This was noted by the OT and PT in the Kelson, Fiechtl, Olsen, and Rule (2009) study with four rurally based families, who reported that telepractice forced them to employ coaching techniques. They described feeling uncomfortable and were unfamiliar with the level of collaboration needed to work with the parents over telepractice, as they tended to be child-centred in their face-to-face visits. Olsen et al. (2012) observed the differences in behaviour of the interventionist between the

telepractice and face-to-face context. There were 17 interventionists involved across 2- years which included the roles of PT, OT, SLT, special education and child

development providers. The interventionist used telepractice and continued with a monthly face-to-face visit with 10 rurally based families. Coaching strategies were used more frequently over telepractice than in face-to-face visits. It was further identified that the parents and the interventionist engaged in more EI programme related discussion, such as their children's health, than in face-to-face visits. This finding aligns with the idea that using a family-centred approach requires greater understanding of families,

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what their daily life looks like and what is important to them (Woods et al., 2011). Other benefits included time and travel cost savings, as noted by studies conducted with rurally based families (Cason, 2009; Kelson et al., 2009; Olsen et al., 2012). These parents commented on the benefits of being able to have more regular sessions (two-to- three times a month instead of once a month), a familiar environment for their children and a safe setting (i.e., for one child who had compromised immune system).

McCullough (2001) specifically focused on SLT delivery of telepractice to five families, four of whom had children with DS and one with Cornelia de Lange

syndrome. The parents and the SLT identified that their children made substantial gains in their communication development. The parents were positive about the programme and indicated that they would recommend this experience to others. Kelson et al. (2009) did not report on the parents’ perception of their children's progress, while Cason (2009) found both parents felt that their children had made progress. Although the parents were generally satisfied with the programme in Olsen et al. (2012), one parent preferred face- to-face visits while another parent reflected on the benefits of both approaches, "In the home visits, [the service provider] did more one-on-one with [child's name] and was able to interact, which he liked. On the virtual visits, she told me ways I should interact with him to get him to talk. Both were good" (p.275). More recently, a comparison study of 48 parents with children with hearing loss, verified that parents in the

telepractice and face-to-face groups perceived similar levels of support, knowledge, and confidence in supporting their children's development (Behl et al., 2017).

Thus far, these small-scale studies contribute evidence toward the feasibility of

telepractice in ECI. Unfortunately, they lack description of intervention procedures and therefore the ability to be replicated. Olsen et al. (2012) had also mentioned choosing “families of various cultural and linguistic origins” (p. 270) without discussing what they were and whether this was consequential. While the experience of telepractice is mainly positive, substantial evidence needs to be obtained to confirm its effectiveness. Of note is that telepractice contributes to the increased adoption of ECI

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2.8.2 The internet-based parent-implemented communication strategies programme.

The Internet-based Parent-Implemented Communication Strategies (iPiCS; Meadan et al., 2016) programme was the only researched telepractice intervention model at the time the present study was implemented. This programme grew out of a face-to-face ECI programme referred to as the Parent-Implemented Communication Strategies programme (PiCS; Stoner, Meadan, & Angell, 2013) discussed in sections 2.6.2 and 2.7.1. The objective of both intervention programmes was to create an effective "coaching model that can easily be adapted to coach parents to implement a wide variety of communication interventions" (Stoner et al., 2013, p. 115) using naturalistic strategies. The steps included:

“(a) share a vision and establish long-term and short-term goals; (b) teach parents the intervention strategies; (c) set session goals and implement the intervention strategy; (d) observe parent, give feedback and evaluate the process; and (e) monitor progress and set new objectives” (Stoner et al., 2013).

The foundation of iPiCS (Meadan et al., 2016) was based on the socially valid and effective PiCS programme (Meadan, Stoner, et al., 2014). A team of 20 reviewers, including parents who have children with special needs, SLTs and special education early childhood teachers, examined pre- and post-intervention videos of eight parent- child dyads presented in a random order. The results indicated that progress was observable between the two videos.

Research on iPiCS (Meadan et al., 2016) investigated three mothers, with children who had been diagnosed with ASD. This programme taught milieu teaching strategies through an initial training session, followed by regular 30-minute coaching sessions, twice weekly for approximately three and a half months. Coaching took place in three phases: (1) developing a plan to practice the strategy (pre-observation), (2) observing the parents practicing the plan (observation) and, (3) reflection and feedback (post- observation). The strategies were introduced one at a time. Video-feedback took place fortnightly, that is reviewing videoed parent-child interactions to highlight the parents’

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progress and areas to continue working on. Similar to outcomes from PiCS (Meadan, Angell, et al., 2014), parents demonstrated the ability to use the strategies accurately following their coaching sessions. The parents indicated a high level of satisfaction with all aspects of the intervention, stating that they felt empowered to use their newly learnt skills. The parents also reported that their children had improved in their

communication skills verbally and non-verbally, had more positive interactions and were more involved in family activities.

The study delivered high fidelity intervention, through completed checklists for the training and coaching components by the SLT, and a second member who reviewed all training session videos and 30% of the coaching session videos. As for the parents’ use of the strategy, a coding manual was used to ensure consistent analysis of parent-child interaction videos. This included videos from before intervention, the training session, all coaching sessions and videos on random non-coaching days to observe for

generalization of the strategy use. Each video was coded by the SLT and a second reviewer. Interrater reliability of at least 80% was needed in each coding category.

The iPiCS (Meadan et al., 2016) intervention study added to the evidence base a clearly defined telepractice programme and research procedures, with robust outcomes for both the parents and their children, which extended to their family context. Although the sample size was limited, these case studies provided detailed information as to the procedures followed and the progress that parents made through a telepractice programme, enabling future the replication of the study. This provided a strong foundation method for the current intervention study.