ABSTRACT
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Purpose

These case studies explored the potential of delivering speech and language therapy via a novel hybrid telepractice approach.

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Method

Using an experimental research design, two parent-child dyads followed four phases in the study: a pre-intervention phase (Phase I), a control phase (Phase II), an intervention phase (Phase III) and a post-intervention phase (Phase IV). Participants’ receptive and expressive language skills were screened in Phase I, for Phase II the control condition was a waiting period of six weeks. After six weeks with no intervention their language skills were re-screened and again after intervention that lasted between six-to-eight weeks. Parent reported outcome measures supported the informal assessment results.

Results & Conclusion

The pilot study offers promising evidence to support the use ofhybrid telepractice teletherapy that includes digital asynchronous telepractice resources in combination with synchronous direct SLT to support parents to support their children's communication development effectively. It urges future investigation into the feasibility of digital SLT resources and intervention, especially focusing on its potential to enhance parents’ engagement in between practice and over time.

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INTRODUCTION
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Background

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Traditional speech-language pathology (SLP) service delivery models require intensive workforce and worldwide there is an insufficient number of Speech-Language Pathologists (SLPs) to address the demand. The pre-pandemic prevalence of child speech, language and communication needs, requiring intervention from SLPs, is estimated to be between 3 and 7% (Bishop et al., 2016; Bishop et al., 2017; Norbury et al., 2016). Of all community services in the National Health Service (NHS) in the United Kingdom (UK), the greatest increase in waiting times with a staggering 73% since October 2019 is for SLP services (NHS Confederation, 2022). Streamlining service delivery models to enable SLPs to reach more clients, and as a result reduce waiting times, were becoming urgent. Since the pandemic, the situation may have been exacerbated by the environmental risks, such as maternal stress and lack of services that the pandemic brought about (Deoni et al., 2021; Khoury et al., 2022).

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The COVID-19 pandemic intensified the urgency for alternative service delivery models after the suspension of in-person services (Hall-Mills et al., 2022; Kwok et al., 2022; Sengupta et al., 2023). A survey undertaken by the Royal College of Speech-Language Therapists (RCSLT) reported that 77% of SLPs experienced increases in workload post-pandemic (RCSLT, 2021). Additionally, the initial results from a longitudinal study in the United States (US) indicate that children born after mid-2020 show significantly lower verbal and nonverbal skills than their counterparts who were born pre-pandemic at the equivalent age (Deoni et al., 2021). In the US there is an average of 59.3 SLPs per 100, 000 persons (Brook, 2023). In the UK, on the other hand, only 17, 240 SLPs are registered [Health and Care Professions Council (HCPC), 2021]. Assuming a total population of 67.33 million in the UK, this represents 25.6 SLPs per 100,000 persons. An insufficient workforce for an ever-growing demand results in longer waiting times for services and an urgent need to address this through alternative service delivery models (RCSLT, 2021). Especially when considering that an estimated 20% of the population will experience communication difficulty throughout their lives (RCSLT, n.d.).

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Telepractice

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Service delivery through online telecommunication platforms, known as telepractice [American Speech-Language-Hearing Association (ASHA), n.d.; World Health Organisation, 2016], has been proposed as a solution to overcome the barriers in supply (Snodgrass et al., 2016; Tosh et al., 2017; Wales et al., 2017; Sengupta et al., 2023). Telepractice has been suggested to be feasible for children with communication disorders and its effectiveness for child and parent outcomes has been explored (Kwok et al., 2022). Initial findings of the uptake of telepractice post-pandemic has suggested that SLPs have more confidence to use telepractice as a service delivery model (Hao et al., 2021).
Barriers in traditional SLP service delivery have been reported due to distance and associated financial expenses for individuals in remote areas (Fairweather et al., 2016), but also internet connectivity issues for rural areas. Telepractice may reduce time and financial expenses related to travelling for SLPs and clients alike, while increasing access to SLP services in underserved contexts (Kingsdorf & Pancocha, 2023; Tosh et al., 2017; Wales et al., 2017).

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However, a prominent barrier to telepractice is the limited evidence on the effectiveness, reliability, and validity of language assessments and intervention used in a virtual setting (Hall-Mills et al., 2022; Tosh et al., 2017). Another reported challenge is the lack of an appropriate online platform and infrastructure for service delivery (Snodgrass et al., 2016; Tambyraja et al., 2021; Wales et al., 2017). Although each service delivery model has its own challenges, evidence supports that factors that influence intervention success interact and may counterbalance or exacerbate each other (Kwok et al., 2022).

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Synchronous vs asynchronous telepractice
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Telepractice may be offered synchronously, asynchronously or in a combination, hybrid, approach (ASHA, n.d.). Synchronous telepractice is when SLP services are offered live or in real-time through a digital platform (ASHA, n.d.; Kingsdorf & Pancocha, 2023). Synchronou telepractice has been used to offer parent coaching (Kossyvaki et al., 2022) in early intervention. The effectiveness of parent-child interaction therapy (PCIT) in addressing communication difficulties among others, and its potential as a telepractice approach, has been established in research (Falkus et al., 2015; Snodgrass et al., 2016; Tosh et al., 2017).

Asynchronous telepractice uses “offline” telepractice through messaging platforms, pre- recorded videos for parent training and remote patient monitoring to deliver services (ASHA, n.d.; Kingsdorf & Pancocha, 2023). The use of asynchronous telepractice could address the lack of SLPs to service the demand as it enables them to increase their caseload, spending less time on each client. Researchers investigating support for parents of children with developmental disorders recommended that parents be supplied with resources (asynchronously) that empower them with the knowledge and skills to support both themselves and their children (Craig et al., 2016). Additionally, parent-led interventions have been demonstrated to be efficient in synchronous teletherapy service delivery, while parent involvement is a predictor of intervention success (Kwok et al., 2022; Zhang et al., 2021).

A hybrid teletherapy approach combines synchronous and asynchronous telepractice (ASHA, n.d.). A combination of asynchronous parent training and synchronous parent coaching has proven to have higher parent fidelity and intervention success, as opposed to either in isolation (Kossyvaki et al., 2022; Sengupta et al., 2023).

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The Noala Approach

Noala was a telepractice platform that aimed to improve access to SLP services through an online infrastructure that supported SLPs in novel, hybrid telepractice. Noala used a combination of digitised asynchronous parent training videos and activities and synchronous parent coaching resulting in a hybrid telepractice approach. Noala offered a secure and reliable, interactive video conferencing platform, tools for patient communication and patient record management for SLPs. For clients, it offered interactive resources, engaging digital exercises to support speech and language development (Noala, 2023). It was accessible to families via any digital device, which transferred the intervention into any everyday activity. The company is now closed for business, but the digital platform remains accessible for charities for free, in open source (CC-0 licence).

The Noala platform was founded by Emilie Spire, the chief executive officer, in collaboration with Sarah Lyons, the UK Clinical Director, and with the support of the Noala core team including specialists with IT, product, and design expertise. These programmes were developed to ensure that the speech-language intervention offered through Noala, was ‘equivalent to standard clinical care’ (ASHA, n.d.). The fundamental components of evidence-
based practice were considered throughout the development and refinement of these programmes (Bolden & Grogan-Johnson, 2022). Clinician expertise was offered with the Noala Clinical Advisory Board and consulting SLT offering services. Child and caregiver perspectives were considered through consistent online tracking and communication with live parent coaching calls. The programmes were based on both internal and external evidence.

Two hybrid telepractice programmes were developed, namely the Noala Communication Boost programme and the Noala Speech Sound programme. SLPs could sign up to become a Noala SLP. They received training in the use of the hybrid telepractice approach and could access the Noala mentoring and resources at any time (Noala, 2023). It was freely available to SLPs who signed up with Noala Pro via any standard internet browser.

Parents could schedule an introductory call via the website with one of the trained Noala SLPs. Both the parent and child had to be present during the initial call. An informal assessment was done to determine which programme suited the concerns of the family best. The programme had three difficulty levels in terms of keyword understanding and the starting level was also established in the first call. An SLP conducted the initial, informal assessment which included: (1) comprehensive medical and developmental case history, (2) informal pre-intervention parent-reported measures of the child’s communication skills, and (3) informal, play-based language screener and age-appropriate formal assessment tool. The parent-child dyad was also shown around the platform. The SLP that completed the initial assessment would have regular follow-up calls to provide synchronous parent coaching. The asynchronous component included pre-recorded parent training sessions, digital exercises and resources (Noala, 2023), based on the principles and strategies of parent-child interaction therapy (PCIT). The interactive Noala platform allowed families to access these activities one theme at a time. It recorded the child’s responses to the keywords and also recorded the child’s verbal responses, or parent elicitation probes, for the flashcards. The consulting SLP could access these results via their patient portal, from which the SLP can open the next theme once the preceding theme has been completed.
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The Noala Communication Boost Programme

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The digital asynchronous components of the Communication Boost programme were themed from concrete (i.e., easiest to comprehend) to more abstract (i.e., most difficult to comprehend), namely food, body parts, animals, transport, colours, and shapes. Each theme contained a pre-recorded parent training video. Each video, featuring the Clinical Director of Noala, explained which strategies and activities can be used by the parent for each theme per developmental domain. She further showed parents how to scaffold strategies and activities to different levels so that the parents could adapt to their child’s age and developmental ability. The developmental domains that were targeted by the programme were attention and listening skills, play and social interaction skills, understanding language, and use of language. The Noala Communication Boost programme considered that each of these domains contributes to overall communication success (Owens, 2017). The programme further included keyword activities for receptive language, and flash card activities for naming, also related to the theme.

Synchronous online coaching calls were scheduled after the completion of each theme. These calls supported the parents to implement the asynchronous strategies effectively and to individualise them to their child’s needs. Through PCI, it is aimed to empower parents in their role as active intervener and advocate for their child’s communication (Klatte et al., 2019). During the live coaching session, the therapist discussed PCI strategies that support improved interactions (Falkus et al., 2015), as well as additional strategies of functional language intervention (Owens, 2014) such as expansion. These are also based on the Noala training that the therapists received. Parent training and parent coaching supports and encourages ongoing opportunities for skill development (Kossyvaki et al., 2022).

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Investigating the potential of the Noala Communication Boost Programme

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To demonstrate the potential of the Noala Communication Boost Programme to support communication skill development two case studies are presented . The procedures detailed in Figure 1 were followed by two parent-child dyads. After eligibility screening, the initial assessment (S1) consisted of the three components used in the Noala Initial assessment protocol for the pre-intervention phase (S1), Phase I. It included (1) a comprehensive medical and developmental case history, (2) informal pre- intervention parent evaluation of the child’s communication skills, and (3) the informal Noala play-based assessment screener (Appendix A) and age-appropriate formal assessment tool. After a six-week waiting or control period, the control condition assessment in Phase II was done. The screener (S2) and, where appropriate , the formal tools were repeated. The level at which intervention had to be started, was advised by the therapist after phase two. Phase III or the intervention phase, involved the completion of the Noala Communication Boost Programme via the digital platform as well as six synchronous parent coaching sessions that served as the clinical wrap-around to the asynchronous intervention. In Phase IV, a post-intervention parent evaluation interview was conducted in addition to the screener (S3) and age-appropriate formal assessment tools.

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An informal screener was completed three times by different therapists to measure progress while accounting for possible familiarity effects on results. The screener was scored according to the protocol in Table 1. Additionally, depending on the age of the child, a formal assessment tool was included in the assessment protocol. The Renfrew Action Picture Test (RAPT; Renfrew, 2019) for ages 3;0- 8;0 was used to further investigate expressive language skills. The digital picture stimuli for the RAPT are freely available for online assessments via the publisher’s website (Routledge, 2023). It includes a series of ten images with associated questions to assess a child’s skill in conveying information as well as specific grammar such as tenses, verb forms and plurals (Routledge, 2023). It is normed against a UK school-based population.

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Participants were offered Noala’s Communication Boost programme for free for their participation in the research study. Additionally, they received a £40 Amazon voucher upon completion of the study, which they were not aware of prior to volunteering to participate.

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Ethical considerations

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Ethics approval was obtained from the Faculty of Medicine and Health Sciences Research Ethics Committee at the University of Buckingham (HWSL230111). The best interest of the participants in the current study took priority above any research aims. Participation in the current research was completely voluntary and dyads could withdraw at any time.

Case study 1

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The first parent-child dyad was a 43-month old male and his mother. Participant 1’s mother reported in the case history that her son started babbling around 6 months of age and that he was a noisy baby. He started using his first words around 11 months and started putting two words together from age 2 years. Participant 1 had grommets placed but had no other existing conditions. He attended nursery part time.
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Asynchronous intervention
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Following the waiting period or control condition, it was advised that participant 1 starts at level two for receptive language and level three for expressive language for asynchronous intervention. The asynchronous intervention component included the parent training videos , flashcard activities for receptive language and naming activities for expressive language. This parent-child dyad only watched one video under the theme “Shapes” as part of the asynchronous intervention. However, for the activities, 50 practice attempts were recorded. The asynchronous intervention facilitated the continuous generalisation of intervention strategies (Kossyvaki et al., 2022) that were discussed and advised in the live parent coaching calls. It was meaningful that the parent reported outcome measures reflected that the parent valued asynchronous materials and how they related to areas of everyday functioning. “It's nice seeing the real life pictures kind of thing because you kind of relate to real life as well and we could do that outside of the actual programme.”

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Synchronous intervention

Participant 1 and his mother attended all six parent coaching sessions with the SLP. Parent- child dyads booked a parent coaching call with the SLP as soon as they were able to complete a theme’s exercises. Completion of a theme's exercises, entailed that the participant completed at least one flash card exercise and at least one key word exercises. The SLT could track the completion of the theme by viewing the scorecard and voice recordings via the online platform. In Case 1, parent coaching sessions were booked on average 15.8 days apart. During coaching calls, the parent and SLP would discuss any challenges or concerns noted by the parent. The SLP would then provide individualised parent coaching based on the feedback provided by the parent during the session. Some PCI strategy guidelines that were implemented for in Case 1 included modelling of speech and language and expansion with short words, including articles, conjunctions and auxilary verbs. The SLP also advised strategies that targeted phonological awareness. Parent reported outcome measures about the synchronous parent coaching component with the SLP was particularly positive: “It has been nice having follow up meetings [with] one of the therapists and her giving us tips.”
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Results

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Informal progress measures as well as parent reported outcomes were positive for participant 1. For the informal screener, that was done initially (S1) after the control waiting period (S2) and again post-intervention (S3), the receptive score showed increases over time although the expressive scores remained fairly stable as seen in Figure 2.

The sensitivity of the screener may have been insufficient to detect progress and compare measures between the initial assessment, after the control waiting period and post-intervention. However, the RAPT scores showed increases in information and grammatical scores as seen in Table 2.

It is noted that during the control condition, progress was noted for the information score, however, no progress was noted in the grammatical score. The grammatical score has increased post-intervention. The mother of participant 1 reported that her child was highly motivated and reminded her of the asynchronous activities. When asked about their experience of the programme, the mother reported: “It's been really interactive which I enjoyed with him.” Although this parent-child dyad did not access the video material as often, the mother reported that she found the videos helpful and insightful.

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The mother finally reported that her son’s language has developed in “leaps and bounds” adding that she will continue to use the programme to develop his skills. Participant 1’s mother did not only feel “reassured”, but that the programme was “structured” in ways that “gave us guided steps into how we can help him a bit more”. The mother reported that she did not “realise online therapy was feasible” and that she would continue SLP support and guidance online.

Case study 2

The second parent-child dyad was a 40-month old male and his mother. In the semi- structured case history interview, the mother reported that the child was using more than 100 words and combining two words. She further reported no co-occurring or medical conditions, but that they had a family history of stuttering. He was attending nursery part-time at the time of data collection. His home language was English.
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Asynchronous teletherapy

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After the S2 screener, the SLP determined that participant 2 should start on level three for both the receptive as well as the expressive activities. The joint goals that the SLP and parent set were to support consistent understanding of three keyword instructions. Additionally, forming subject-verb-object sentences consistently was another identified goal. This participant watched four videos under the themes “animals”, “transport”, “body parts”, and "colour” as part of the asynchronous intervention. Forty-seven practice attempts were recorded by the online platform for digital exercises.
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Synchronous teletherapy

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For case 2, the parent-child dyad booked parent coaching sessions with the SLT 14 days from each other. The positive feedback on the synchronous component was supported in Case 2 as well: “It's also helped being able to speak to [an SLP] on a regular basis about how he's doing, and what I need to do next.” The PCI strategies used, were offering choices and opportunities for increased interaction. The SLP also targeted pragmatics through strategies such as turn taking and asking questions between the participant and peers facilitated by the parent. The participant was able to follow the programme well at home and therefore the SLP scaffolded the programme up by asking the parent to add where and when questions to the existing activities to facilitate expansion.

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Results

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Participant 2 also showed increased receptive language scores according to the language screener with fairly stable expressive language measures as indicated in Figure 3.

During the control period (between the S1 and S2 screener) it is noted that the receptive language score decreased and the expressive language score remained stable. Post- intervention scores for receptive language increased and expressive language decreased slightly. The sensitivity of the screener should be considered in future investigations.

Overall progress correlated with the reports from the mother of participant 2. “I feel as though he has improved at home, especially with how many words he's using. He's putting together sentences now and he seems a lot more confident to just talk.” It is promising that the parent of Participant 2 noted that they learned a great deal about their own behaviours from the intervention. The parent expressed that they felt enabled to help and support their child. “It's made me think differently about the different ways that I communicate.” In case 2, the parent also reported that they would like to continue with telepractice even if they were able to access in-person services.

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CLINICAL IMPLICATIONS

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When considering gaps in traditional service-delivery models and lack of SLPs to address the needs for early communication intervention, the urgency for alternative service delivery models becomes apparent.

The pilot study offers promising support for the use of hybrid telepractice that includes digital asynchronous telepractice resources in combination with synchronous SLP to support parents to support their children's communication development. It urges future investigation into the feasibility of digital SLT resources and intervention, especially focusing on its potential to enhance parents’ engagement in between practice and over time. The results showed that the combination of an asynchronous programme on a specialised platform and regular consultation with an SLP has potential to increase communication skills of children immediately post-intervention. Evidence-based practice principles further support this model of service delivery (ASHA, n.d.). Placing parents in a role as an advocate for their children and empowering them with the strategies and knowledge to take an active role has shown promise (Hibbard and Gilburt 2014; Klatte et al., 2019). The Noala Communication Boost programme further allows for consistent internal evidence gained from the SLP expertise in frequent parent coaching (John et al., 2023). In combination with external evidence supporting PCIT in traditional (Klatte et al., 2019) as well as telepractice intervention models (Snodgrass et al., 2016).

The Noala Communication Boost programme offered access to digital tools that were engaging and easy to use at home which may encourage parents to continue implementing intervention strategies with their children in between coaching sessions. The correlation between the digital product, the frequency of at-home practice and the clinical outcome would need to be further investigated.

The long-term outcomes of the intervention programme should be investigated in future. In addition, further research may support the development of more programmes based on the novel model of service delivery presented here for a range of additional disorders. The current findings indicate that after completing the Noala Communication Boost programme, parents reported decreased concern about their child’s communication skills. Furthermore, they reported that their children had increased communication skills and that parents felt enabled to support their children. The case history results of Participant 2 indicated that parental concern was grounded in family history of communication difficulties and apparent developmental delays. This not only supports previous findings that parental concern often precedes diagnosis and intervention (McKean et al., 2016) but also highlights that parental concerns arise from known risk factors, which underscores the importance of parental concern as a valuable predictor (Cuomo et al., 2021) that can allow for early and even preventative service delivery. Parent reports further recognised that both asynchronous digital resources as well as live parent coaching added value and supported the intervention, underlining the importance of their role as intervener (Klatte et al., 2019).
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LIMITATIONS AND FUTURE DIRECTIONS

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Although the study provided insight from multiple perspectives into the effectiveness of the Noala Communication Boost Programme, it is important to mention some limitations. As a preliminary proof of concept, the need for a large-scale study with sensitive assessment measures to quantify current findings reliably, is needed. A large-scale study should consider carefully the homogeneity of participants with robust case history and inclusion criteria. Appropriate assessment measures remains a well-known barrier to appropriate service delivery in telepractice (Hall-Mills et al., 2022; Tosh et al., 2017). The current study has again confirmed the need for appropriate, sensitive assessment tools for online use. In addition, assessment of other domains including progress measures for play and social skills may be valuable in further research.

It is also worth noting that parent reported outcome measures relied on parents’ perceptions on how much they felt supported. Robust parent reported outcome measures as well as evidence of improved parent-child interactions may support these informal findings in future research.

For this study, it was decided not to have a control group as the ethical implication of denying or delaying intervention was not justified. The control period that was implemented in the current study did not account for developmental changes over time. Evidence suggests that service delivery models may be adapted over the course of a child’s development (Kwok et al., 2022). The control condition or waiting period may however be useful in future research to determine the effect of the intervention.
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CONCLUSION

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The need for equitable service delivery in SLP on the one hand and the possibilities of digital solutions on the other have never been more congruous. SLPs require more efficient service delivery models to address the increasing demand for services. The current case studies concluded that the Noala Communication Boost programme as a hybrid telepractice intervention programme has potential to support SLPs in optimised service delivery. . The programme supports the empowerment of parents to advocate for their children and take an active role in intervention which may be effective in increasing their children’s communication skills.
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