Legislación vigente aplicable a la obra

Although speech pathology intervention has traditionally been delivered by a speech pathologist, it is possible for the treatment to be delivered in part, or in the majority, by a trained caregiver, teacher, speech-language therapy assistant (SLTA), allied health assistant or even a computer (SLTA, Law et al., 2017). These alternative treatment delivery agents enable the client to potentially receive higher treatment intensity than would be available from the speech pathologist

alone (Baker & McLeod, 2011; Law et al., 2017; Lim et al., 2017). When the alternative delivery agent provides treatment in a natural setting, such as the client’s home or classroom, generalisation can be enhanced (Roberts & Kaiser, 2011). For service providers, there is a potential cost saving associated with employing a SLTA rather than a speech pathologist, and no salary costs are associated with service provided by a caregiver or teacher. Even when the time required to train parents is considered, parent-delivered treatment is more cost effective than treatment delivered by a speech pathologist (e.g. Barnett, Escobar, & Ravsten, 1988).

Despite the prevalence of non-speech pathologist involvement in treatment (see ‘Use in speech pathology’ below), there are significant gaps in the detail provided in the literature about the nature of this involvement (Sugden, Baker, Munro, & Williams, 2016). There are three broad purposes this involvement may take: to facilitate generalisation (e.g. PROMPT, Dale & Hayden, 2013), to supplement the intervention provided by the speech pathologist (e.g. PACT, Bowen, 2010) and to be the predominant intervention agent (e.g. Onslow, Packman, & Harrison, 2003, Eiserman et al., 1990). Each of these three broad types of involvement involves myriad tasks, methods and levels of intensity, resulting in almost limitless permutations of involvement by other intervention agents (Sugden et al., 2016). For the purposes of this thesis, another agent is considered the treatment delivery agent when they (a) establish a situation that allows for administration of a therapeutic dose and (b) respond to the client in such a way as to encourage higher accuracy with the targeted skill (e.g., provide accurate feedback on productions).

1.3.3.1 Use in speech pathology

Speech pathologists, internationally, involve other agents in the delivery of treatment (e.g. UK, Joffe & Pring, 2008; Germany, Keilmann et al., 2004; South Africa, Pascoe et al., 2010;

Australia, Watts Pappas et al., 2008). More than 85% of Australian paediatric speech pathologists provide therapy via parents, and more than a third provide therapy via teachers and teacher’s aides (Baker & McLeod, 2011). Involvement of other agents occurs across client age groups and impairments (e.g. Onslow et al., 2003; Roberts & Kaiser, 2011; Togher, Power,

Rietdijk, McDonald, & Tate, 2012). As discussed, there is a lack of clarity regarding the nature of this involvement. For example, when investigating the nature of parent involvement, questionnaire studies about routine service delivery have variously asked respondents to indicate whether they use ‘parent involvement’ (Joffe & Pring, 2008, p. 159), whether they ‘give exercises’ (Keilmann et al., 2004, p. 54) and whether they ‘incorporate home programmes’

(Pascoe et al., 2010, p. 75).

1.3.3.2 Efficacy

As one of the foci of this thesis is caregiver-provided treatment, this section predominantly focuses on the efficacy of parents as treatment delivery agents. In the literature, there are frequent statements about the importance of caregiver involvement for the success of treatment, particularly for paediatric clients (e.g. Glogowska, Campbell, Peters, Roulstone, & Enderby, 2002; Law, Zeng, Lindsay, & Beecham, 2012; Roberts & Kaiser, 2011). However, the specific nature of caregiver involvement can vary markedly between studies and between clinical populations. Although clinic sessions supplemented with caregiver home practice are effective for many communication impairments—for example, childhood language impairment(e.g.

childhood language impairment, Roberts & Kaiser, 2011; paediatric speech sound disorder, Bowen & Cupples, 1999)—it can be difficult to determine the relative contribution made by the caregiver agent to the outcome. The reason for this difficulty is twofold. Firstly, information about the tasks performed by the caregiver and about the frequency and fidelity of the tasks is limited (Kaderavek & Justice, 2010; Sugden et al., 2016). Secondly, comparisons between participants receiving the same intensity of speech-pathologist-delivered treatment with caregiver involvement and without caregiver involvement are rare.

The difficulty in determining the relative contribution of the intervention agent to the treatment outcome was demonstrated by Eiserman et al. (1990) in their study of the cost effectiveness of service delivery for preschool-aged children with speech impairments. Eiserman and colleagues compared parent-delivered and therapist-delivered treatment for preschool-aged children with

speech and language impairments. The children were allocated to therapy either in a pair with a speech pathologist at the clinic (1-hour treatment, one session per week) or individually at home with a trained parent (20–30 minutes, four times per week) for 7 months, using traditional articulation therapy. Following treatment, no significant differences were found between the two treatment conditions on the speech measures, although the parent-delivered condition resulted in better performance on the expressive language measures. However, the numerous differences between the two groups, such as setting (clinic vs. home), context (group vs. individual), intervention agent (clinician vs. parent), dose-frequency (once per week vs. four times per week) and cumulative intervention intensity (1,680 mins in the clinic vs. 2,240–4,460 mins at home) make it impossible to determine which feature or features were responsible for the treatment outcome.

It is easier to determine the efficacy of caregiver-delivered intervention when it is delivered exclusively by the caregiver and compared with either no treatment or treatment by a speech pathologist. Although these types of studies are scant (see Sugden et al., 2016, for a review), the outcomes are generally positive. A meta-analysis of caregiver-provided therapy in allied health found that caregiver-provided therapy was better than no therapy for stuttering and for expressive language (Lawler, Taylor, & Shields, 2013). Similarly, childhood SSD treatment provided by trained caregivers is better than no treatment (e.g. Broen & Westman, 1990). The limited investigations of the efficacy of caregiver-provided treatment compared with clinician-provided treatment indicate that treatment has similar levels of effectiveness for expressive language and SSDs (Lawler et al., 2013). There is no research investigating the outcomes of caregiver-provided treatment for CAS.

1.3.3.3 Other considerations

Parents prefer treatment to be delivered by a clinician than by another provider. They consider the speech pathologist to be the expert, and they expect the clinician to carry out the intervention (Carroll, 2010; Glogowska et al., 2002; Hayhow, 2009). For example, only 4% of Australian

parents wanted their child to be treated using parent training or a home program (Ruggero et al., 2012). Some parents place less value on intervention than their speech pathologists do, due to their differing perspectives regarding speech and language development, the child’s difficulties and the need for intervention (Carroll, 2010; Davies, Marshall, Brown, & Goldbart, 2016;

McAllister et al., 2011), as predicted by the health belief model (Carpenter, 2010). There may be practical reasons for parents not being able to complete intervention with their children, such as difficulty ensuring child compliance and not having sufficient time to implement the treatment (McAllister et al., 2011). Indeed, clinicians identify that limited parent engagement in the therapeutic process affects the delivery of home-based speech practice (Lim et al., 2017), and clinicians would like parents to be more involved (Baker & McLeod, 2011; Lim et al., 2017).

The time required to train another intervention agent must be balanced against the potential benefits. Clinicians in the UK spend more time on training parents and other professionals than they do on providing direct treatment (Pring, Flood, Dodd, & Joffe, 2012). Therefore, to determine whether time spent on parent training is time well spent, it would be necessary to first understand the effectiveness of parent training on treatment outcomes. Another factor to consider regarding parent-delivered treatment is whether parents deliver the intervention accurately (i.e., with high treatment fidelity). High treatment fidelity is associated with the strongest treatment outcomes (Kaderavek & Justice, 2010). Lastly, there are indications that some treatments or conditions may be too complex for someone other than a speech pathologist (Sugden et al., 2016).

For example, it is not yet known whether it will be appropriate for parents to deliver therapy to children with CAS, a highly complex condition.

1.4 Stakeholder perspectives