Speech and Resonance Disorders in Children With Cleft Palate: Diagnostic Evaluation and Current Speech Therapy Modalities

This article will provide an overview of how speech and resonance can be impacted in children with cleft palate. The authors will outline evidence-based assessment and treatment approaches commonly used for children with cleft palate and provide information on current initiatives to provide speech therapy. The methods discussed will be the use of telehealth to provide access to speech therapy for patients in areas without speech-language pathologists and the use of speech therapy camps to offer intensive, limited-duration speech therapy for groups of children due to the lack of trained providers in certain geographical regions.

Teleaudiology Services in Australia: A National Survey of Hearing Health Care Consumers Amid the COVID-19 Pandemic

PURPOSE

The aim of this study was to investigate the perspectives of Australia-based hearing health care consumers regarding the (a) provision and utilization of teleaudiology services, (b) experiences with teleaudiology, and (c) barriers and enablers to future teleaudiology use.

METHOD

A national prospective self-report online survey was completed between April and October 2020, amid COVID-19. Data were analyzed using descriptive statistics (closed-answer items) and content analysis (open-text responses). A total of 381 participants (Mage = 72.07 years ± 10.08, 142 females) were recruited from different states and territories of Australia.

RESULTS

Despite positive outcomes reported by those who undertook teleaudiology appointments during COVID-19, results indicate low-consumer teleaudiology uptake. It can be inferred that consumers were not aware of teleaudiology as an appointment option, clinicians/clinic staff had not informed and/or supported teleaudiology as an option, and biases existed that prevented teleaudiology being more widely adopted. It is unclear whether consumers who were eligible for government subsidies understood that teleaudiology appointments were reimbursed through government funding. Barriers to future teleaudiology uptake were largely related to concerns regarding confidentiality and privacy.

CONCLUSION

Low consumer uptake of teleaudiology appointments appears to be driven by consumer preference for in-person services, which appears to be driven by lack of knowledge regarding the availability and effectiveness of teleaudiology.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25619808.

Clinical effectiveness of telerehabilitation in voice therapy programs for dysphonia

PURPOSE

The main aim of this study was to investigate the clinical efficacy of speech therapy, delivered via tele-practice to patients with dysphonia. A secondary aim was to verify whether a telerehabilitation-only protocol could have a clinical efficacy similar to a combined telerehabilitation and in-person approach.

METHODS

Thirty-two consecutive patients undergoing telerehabilitation for dysphonia were retrospectively considered. Patients were divided into two groups: those who received combined in-person and telerehabilitation treatment, and those who underwent telerehabilitation only.

RESULTS

Overall, patients included in this study showed a significant improvement in their VHI-10 scores after treatment (p < 0.001). Such an improvement was also significant in both combined therapy and telerehabilitation only groups (p = 0.019, and p = 0.002, respectively). A significant reduction in general degree of dysphonia (G), roughness (R), breathiness (B) and strain (S) scores (p < 0.001, p = 0.012, p < 0.001, and p < 0.001, respectively) was noticed over the whole sample after treatment. The same parameters showed a significant improvement also in the combined therapy group, while in the telerehabilitation only group, only G, B and S scores significantly improved. Mean phonation time, Jitter and Shimmer values significantly improved in the overall sample as well as in the combined therapy group. A significantly more favorable spectrographic class relative to the vowel /a/ was found after treatment in the whole sample, as well as in both combined therapy and telerehabilitation only groups (p < 0.001, p = 0.002, p = 0.004, respectively).

CONCLUSION

This study's results seem to support telerehabilitation as a potentially effective tool to administer speech therapy in dysphonic patients, both as a single modality and in combination with traditional in-person sessions. To better characterize the clinical results of telerehabilitation in dysphonia treatment, large-scale prospective investigations are mandatory.

Telehealth for Treatment of Pediatric Dysphonia

BACKGROUND

Vocal fold nodules are the most common etiology of chronic dysphonia in the pediatric population. Voice therapy is an effective first line of treatment, with increasing evidence supporting the use of telepractice in speech pathology. Despite this, there is limited data on its effectiveness in the pediatric population. The aim of this retrospective study was to investigate the feasibility and efficacy of telepractice in delivering voice therapy to children diagnosed with vocal fold nodules.

METHODS

A retrospective review was conducted of patients treated with virtual voice therapy from April 2020 to June 2021. Patients were included if diagnosed with vocal fold nodules, 2-18 years of age, and completed therapy in a virtual format. Data includes demographics, Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) scores and pediatric Voice Handicap Index (pVHI) scores.

RESULTS

Twenty-three children were included, 17 (74%) male and six (26%) female (with an age range of 2.4-9.9 years at the start of therapy). Prior to treatment, the average CAPE-V Overall Severity score was 37.9 (SD 13.8); the average posttreatment score was 22.4 (SD 10.2). The average pVHI total score prior to treatment was 26.3 (SD 12.1), with an average posttreatment score of 20.2 (SD 11.7). Patients who underwent virtual voice therapy had improved posttreatment CAPE-V severity scores than those prior to treatment (average difference = -15.5 points; 95% CI: -8.3 to -22.7; P < 0.001). An increased number of therapy sessions was associated with both higher initial CAPE-V severity scores (r = 0.72; P < 0.01) and a greater decrease in posttreatment CAPE-V scores (r = -0.55; P < 0.01).

CONCLUSION

Virtual voice therapy may be feasible and efficacious in treating dysphonic children diagnosed with vocal fold nodules. Significant improvements were found in perceptual CAPE-V scores in overall severity; positive changes were also seen in parental measures of quality of life. Delivery of voice therapy in a telehealth format may increase access of care and should be considered as a treatment option.

Patient experience of telehealth appointments in head and neck cancer services during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic resulted in rapid changes to head and neck cancer (HNC) services. Multidisciplinary team (MDT) face-to-face appointments were converted to telehealth appointments (telephone and video-call) to reduce the risk of COVID-19 transmission. The literature exploring HNC patient experience of these appointment types is limited.

AIMS

To explore patient experience of telehealth appointments at one UK centre during the COVID-19 pandemic, as well as the variables that may influence patient preference for virtual or face-to-face appointments.

METHODS & PROCEDURES

A survey-based study design was used, with closed questions and open text options to capture the views of the participants. Quantitative data were analysed using descriptive statistics. Open text data was used to add depth to the findings.

OUTCOMES & RESULTS

A total of 23 participant surveys were returned. Six categories were identified: Usability; Information receiving & giving; Satisfaction; Emotions and comfort; Rapport; and Travel time and cost. Overall, participants gave positive responses to each category and indicated that telehealth appointments met their needs. Areas for clinical consideration are highlighted. Variables such as age, travel distance from hospital site, fear of COVID-19 and information technology (IT) access did not appear to influence patient preference for appointment type.

CONCLUSIONS & IMPLICATIONS

Going forward, telehealth may be considered for use in combination with face-to-face appointments in the HNC pathway. Areas for further development include a 'telehealth screening tool' that may help to identify those patients most appropriate for these appointment types, or who require support to access them.

WHAT THIS PAPER ADDS

What is already known on this subject The COVID-19 pandemic resulted in major disruption to HNC centres across the world. Services adapted to meet the needs of patients with many implementing telehealth into pathways. Studies exploring telehealth in speech and language therapy (SLT) services with the HNC population indicate positive results. It is clear telehealth has a role in modern healthcare and should not be viewed as a temporary solution to the pandemic. It is, however, recognized that embedding telehealth into pathways is not straightforward and requires ongoing review and evaluation, which includes patient and clinician perceptions. What this study adds to the existing knowledge The service evaluation gives insight into HNC patient experience of telehealth appointments for MDT clinics (led by SLT, dietician and clinical nurse specialist) during the COVID-19 pandemic. Overall, patients report a positive experience of telehealth in the HNC pathway and are willing to accept this platform into their healthcare. Areas for clinical consideration are highlighted. What are the actual and clinical implications of this work? This findings of this service evaluation can be used to support the co-design of HNC pathways which embed telehealth as an option for patients. Areas that were important to the participants are highlighted; this includes the timing of telehealth appointments in the pathway, the need to meet the MDT face to face and the positive benefit of cost savings. The authors suggest a telehealth appointment screening tool as an area for future development.

Describe the population receiving orthotic/prosthetic services using telehealth in Australia, and their experience and satisfaction: a quantitative and qualitative investigation

PURPOSE

Telehealth may help meet the growing demand for orthotic/prosthetic services. Despite the resurgence of telehealth due to COVID-19, there is limited evidence to inform policy and funding decisions, nor guide practitioners.

METHODS

Participants were adult orthosis/prosthesis users or parents/guardians of child orthosis/prosthesis users. Participants were convenience sampled following an orthotic/prosthetic telehealth service. An online survey included: demographics, Telehealth Usability Questionnaire, and the Orthotic Prosthetic Users Survey - Client Satisfaction with Services. A subsample of participants took part in a semi-structured interview.

RESULTS

Most participants were tertiary educated, middle-aged, female, and lived in metropolitan or regional centres. Most telehealth services were for routine reviews. Most participants chose to use telehealth given the distance to the orthotic/prosthetic service, irrespective of whether they lived in metropolitan cities or regional areas. Participants were highly satisfied with the telehealth mode and the clinical service they received via telehealth.

While orthosis/prosthesis users were highly satisfied with the clinical service received, and the telehealth mode, technical issues affected reliability and detracted from the user experience. Interviews highlighted the importance of high-quality interpersonal communication, agency and control over the decision to use telehealth, and a degree of health literacy from a lived experience of using an orthosis/prosthesis.

Core components of project-based intervention after acquired brain injury: Delivering meaningful groups online

BACKGROUND

Rehabilitation for cognitive-communication impairments following brain injury can be complex given the heterogenous nature of impairments post injury. Project-based intervention has the potential to improve communication skills and create a meaningful real-life context where individuals collaborate to develop a concrete product, which benefits others. While evidence for this intervention is emerging, the COVID-19 pandemic prompted increased use of telehealth interventions to serve people with brain injury. This paper aims to describe a framework for the delivery of project-based intervention via telehealth within community rehabilitation settings; and present several case studies of telehealth groups completed in the United Kingdom and the United States during the COVID-19 pandemic.

METHODS

A working group was formed to map the components of project-based intervention onto the rehabilitation treatment specification system (RTSS). This system is a conceptual framework that helps to explain the link between treatment theory and ingredients, allowing a clinician to clearly understand how and why a treatment works. First, a literature search was completed to identify eligible studies on project-based intervention after brain injury. Second, those studies were thematically mapped onto the RTSS to identify important intervention components. Third, the presence of these components was assessed for community brain injury groups delivered via telehealth in the United Kingdom and United States. These groups were further described using a taxonomy of social activities that help to describe the degree of meaningful social engagement.

RESULTS

The literature was described with a thematic RTSS summary. Treatment aims focus on skills training and self-efficacy, advocacy and self-empowerment, emotional well-being and quality of life, and collaboration and community belonging. Treatment ingredients involve a range of cognitive and behavioural supports to deliver meaningful activities and contexts to complete a project. Mechanisms of action involve learning by doing and cognitive and affective information processing. All four telehealth groups conducted in the United Kingdom and United States involved at least three treatment aims, >7 targets, and >8 treatment ingredients. All groups reported positive experiences from activities that involve working collaboratively to help others and contribute to society.

CONCLUSIONS

Project-based intervention delivered via telehealth has the potential for supporting people with acquired brain injury to improve their communication skills and engage in meaningful, collaborative activity. Application of the RTSS helps clinicians to understand the aims and therapeutic ingredients (or clinician activities) through which a person with brain injury may achieve specific treatment targets during the rehabilitation process.

WHAT THIS PAPER ADDS

What is already known on the subject Project-based interventions have the potential to improve cognitive, self-regulatory, behavioural and social communication skills, renegotiate identity and reaffirm sense of self, providing a positive impact on quality of life for persons with acquired brain injuries. Projects serve as a context for meaningful engagement for individuals in the chronic phase of traumatic brain injury recovery, without fulfilling work, family or social responsibilities. However, most published research has involved in-person projects and few projects have been delivered via telehealth. What this paper adds to existing knowledge While past published works have shared core principles of intervention, a variety of projects, durations, dosages and methods have been employed. The current paper provides a framework to support more consistent implementation. By mapping previous project-based interventions to the RTSS, clinicians will have a better understanding of the aims, targets, ingredients and theoretical underpinnings of project-based interventions. In the wake of the COVID-19 pandemic, the shift to telehealth moved interventions to a virtual context. The four case projects in this paper demonstrate that it is possible to conduct project-based interventions via telehealth and provides a clear description to guide clinicians in their delivery. What are the potential or actual clinical implications of this work? This work begins to build the foundation for more rigorous, empirical examination of project-based interventions. By mapping project-based interventions to the RTSS, core aims, targets and ingredients are established that can be objectively examined. This investigation also provides a road map for clinicians who wish to implement this complex intervention.

Can Resident Auditory-Perceptual Voice Assessments Predict Medical Urgency of Voice Disorders?

BACKGROUND/OBJECTIVES

Growing reliance on telemedicine has created new triaging challenges. This study investigated how effectively otolaryngology resident auditory-perceptual voice assessments performed via telemedicine determined the need for urgent in-person clinic visits.

METHODS

Twelve otolaryngology resident physicians (PGY1-PGY5) performed auditory-perceptual assessments on 25 voice samples recorded during initial voice evaluations. Voice samples were balanced in severity and taken in equal numbers from patients with the following diagnoses: benign laryngeal lesions, laryngeal cancer, functional voice disorders, laryngeal edema (associated with LPR), and laryngeal paralysis/paresis. Urgent diagnoses were defined as laryngeal cancer and severe unilateral laryngeal paralysis. For each voice sample, residents were initially blinded to patient medical history. Residents rated severity of voice disorder, predicted patient diagnosis, and determined the urgency of seeing the patient in clinic. Residents then reviewed information from the patient's medical history and again rated urgency of voice disorder.

RESULTS

On average, residents identified urgent voice disorders in 56% of cases. After reviewing medical history, this number significantly increased to 77% (P = 0.001). Voice severity, smoking history, time since onset, and course of symptoms were considered most influential when determining medical urgency of voice patients. Year in residency program had no effect on rating accuracy. As expected, diagnostic accuracy of auditory-perceptual assessments was low, ranging from 40% for laryngeal paralysis/paresis to 5% for laryngeal edema.

CONCLUSION

Auditory-perceptual voice assessment, combined with medical history, predicted most medically urgent voice disorders. Further work should investigate if task-specific training might improve these results and which medical history items are most critical. Until accuracy of auditory-perceptual assessment of medical urgency is improved, these data underscore the importance of laryngeal examination in identifying medical urgency and etiology of dysphonia.

A scoping review of virtual synchronous intervention studies in preschool rehabilitation

PURPOSE

To summarize the available evidence for the delivery of synchronous virtual rehabilitation intervention services for preschoolers and to identify key factors associated with virtual intervention.

METHODS

Five databases were searched to identify peer-reviewed articles that assessed virtual interventions for preschoolers delivered by rehabilitation health professionals including physical therapists, occupational therapists, speech-language pathologists, audiologists, and their associated assistants. Relevant data regarding demographics, technology, mode of service delivery, timing, engagement, and measurement data were extracted, and charted. Data were then summarized quantitatively using frequency counts, and qualitatively using descriptive summaries.

RESULTS

Sixteen studies were identified. Virtual interventions primarily targeted language difficulties or disorders, therefore most services were delivered by a speech-language pathologist or audiologist. Most interventions were delivered using Skype or Zoom on a weekly basis. Various technological features (e.g., phonology software, 'e-helpers') were included, and multiple activities (e.g., playdough, bubbles) and strategies were used to support engagement.

CONCLUSION

This scoping review provides current knowledge about the delivery of virtual rehabilitation interventions for preschoolers to help guide best practices for clinicians. Future research could assess the validity of existing outcome measures in the virtual environment, and outline optimal session length and frequency for virtual preschool interventions.

Telehealth Awareness, Perception, Practice, and Influence of the COVID-19 Pandemic: A Questionnaire to Speech-Language Pathologists and Audiologists

Introduction: The objective of this work was to investigate Speech-Language Pathologists' (SLPs) and audiologists' telehealth awareness, experience, and perception in terms of applicability, effectiveness, barriers, facilitators, and the influence of the coronavirus disease 2019 (COVID-19) pandemic on telehealth practice. Methods: A questionnaire was developed and validated based on relevant literature, authors' clinical expertise, and a published survey. Sample size was determined through power analysis, and participants were recruited using a snowball-sampling technique. Results: Ninety-five (n = 95) clinicians completed a survey. A majority (87.4%) reported awareness of and 68.4% reported experience with telehealth. The SLPs (86.4%) had more experience than audiologists (38.9%). Overall, 78.5% first used telehealth during the COVID-19 pandemic, with no significant difference in telehealth use during versus after the pandemic lockdown; 63.8% reported telehealth being less effective than in-person. However, there were differences in perceived telehealth effectiveness: Telehealth was significantly more effective for consultations and counseling, with adults aged 18-40 years; and clients with fluency and speech sound disorders. The highest significant barrier to telehealth delivery was network issues, and available workplace resources was the highest facilitator although this was not significant. Conclusions: Most clinicians were aware of telehealth, had a positive attitude toward it, and had experience using telehealth. More SLPs than audiologists used telehealth. The COVID-19 pandemic had a positive influence on telehealth service provision with an increase in use that was maintained after in-person services were re-initiated. Perceived effectiveness of telehealth services varied depending on the type of clinical service, the client's age, and diagnosis. These factors must be considered while planning telehealth services in Speech-Language Pathology and Audiology.

Telehealth practice in aphasia: A survey of UK speech and language therapists, with a focus on assessment

BACKGROUND AND OBJECTIVES

Evidence suggests telehealth in speech and language therapy can enhance access to care, cost-effectiveness and satisfaction. However, little is known about use of telehealth in the United Kingdom. Moreover, many assessments/outcome measures for aphasia have been tested for face-to-face administration only, posing challenges to reliable use within the telehealth context. We explored the experiences and views of speech and language therapists (SLTs) working with people with aphasia on using telehealth to conduct assessments/outcome measures, perceived barriers and facilitators in telehealth, and their priorities for research in telehealth aphasia assessment.

METHOD

We explored views of UK SLTs through an online cross-sectional survey (2021) delivered through the Qualtrics platform. The survey covered three main areas: (i) participant demographics; (ii) experience of using telehealth and doing telehealth assessments with people with aphasia post-stroke during the COVID-19 pandemic; and (iii) plans for telehealth post-pandemic. Response formats included yes/no, multiple choice, 5-point Likert scales and open-ended text responses. The survey was expected to take no more than 10 min to complete. Survey data were analysed through descriptive statistics and content analysis of open-ended questions.

RESULTS

One hundred twenty-four SLTs responded to the survey. The majority (>80%) used telehealth during the COVID-19 pandemic and >90% planned to continue to use telehealth in the future. The most used platforms were Zoom, Microsoft Teams and Attend Anywhere. Access to internet and telehealth platforms, and practical problems (e.g., difficulties sharing resources online, limited functionality of telehealth platforms for assessment) were common barriers. Therapists highlighted that training, resources and materials that assist the administration of assessments were important. Most participants responded that there was a need for existing measures to be tested for administration via telehealth (n = 68, 70.8%). Participants overall felt there was a need for online interactive assessments, more online resources that have been trialled for use via telehealth, accessible formats for resources for people with aphasia and clear instructions for how people with aphasia can access resources.

CONCLUSIONS

This study provides new insights into the current use of telehealth assessment with people with aphasia in the United Kingdom and directions for future research. Barriers and facilitators identified can support the implementation of telehealth assessment in SLT services.

WHAT THIS PAPER ADDS

What is already known on the subject The use of telehealth in speech and language therapy has advantages in terms of access to care, cost-effectiveness and satisfaction with care. However, little is known about the use of telehealth in aphasia rehabilitation in the United Kingdom, especially in the area of assessment and outcome measurement. What this paper adds to existing knowledge This study identified that the majority (>80%) of aphasia therapists used telehealth during the COVID-19 pandemic and >90% planned to continue to use telehealth in the future. A need was identified for existing measures to be tested for administration via telehealth and for training, resources (e.g., online interactive assessments) and materials (e.g., accessible formats for people with aphasia). What are the potential or actual clinical implications of this work? To facilitate the successful implementation of telehealth assessment, there is a need for measures validated for use via telehealth and more online resources that have been trialled for use via telehealth.

Towards Automated Vocal Mode Classification in Healthy Singing Voice-An XGBoost Decision Tree-Based Machine Learning Classifier

Auditory-perceptual assessment is widely used in clinical and pedagogical practice for speech and singing voice, yet several studies have shown poor intra- and inter-rater reliability in both clinical and singing voice contexts. Recent advances in artificial intelligence and machine learning offer models for automated classification and have demonstrated discriminatory power in both pathological and healthy voice. This study develops and tests an XGBoost decision tree based machine learning classifier to develop automated vocal mode classification in healthy singing voice. Classification models trained on mel-frequency cepstrum coefficients, MFCC-Zero-Time Windowing, glottal features, voice quality features, and α-ratios demonstrated 92% average F1-score accuracy in distinguishing metallic and non-metallic singing for male singers and 87% average F1-score for female singers. The model distinguished vocal modes with 70% and 69% average F1-score for male and female samples, respectively. Model performance was compared to human auditory-perceptual assessments of 64 corresponding samples performed by 41 professional singers. The model performed with approximating or subpar performance to human assessors on task-matched problems. The XGBoost gains observed across tested features reveal that the most important attributes for the tested classification problems were MFCCs and α-ratios between high and low frequency energy, with models trained on only these features achieving performance not statistically significantly different from the best tested models. The best automated models in this study do not yet match human auditory-perceptual discrimination but improve on previously reported F1-average accuracies in automated classification in singing voice.

Virtual nourishment: Paediatric feeding disorder management with telepractice amidst COVID-19: An allied health perspective

PURPOSE

The rapid adoption of telepractice services by health professionals was necessary to maintain service continuity for children with paediatric feeding disorders during the COVID-19 pandemic, during periods where in-person therapy was restricted. The aim of this study was to explore clinical perspectives and reflections on the use of telepractice for managing paediatric feeding disorders during the pandemic.

METHOD

A post-positivist qualitative approach using thematic analysis was adopted. This study seeks to understand participants' experiences and thoughts from allied health professionals from speech-language pathology, occupational therapy, and dietetics working with paediatric feeding in Western Australia. All participants delivered at least 10 telepractice sessions to children from birth to 12 years with a paediatric feeding disorder. Braun and Clarke's six-step thematic analysis process was used to analyse the data inductively.

RESULT

Eleven allied health professionals representing eight clinical settings in Western Australia, including speech-language pathology, occupational therapy, and dietetics, working with paediatric feeding were recruited. The results revealed four themes: families becoming the catalyst of change, clinician comfort over confidence, insights into authentic mealtimes, and the paradox of choice.

CONCLUSION

This study highlighted the need to build clinicians' confidence and competence, and the provision of service guidelines and training. Although many clinicians had positive experiences with telepractice, most returned to in-person delivery once COVID-19 restrictions were lifted, emphasising the importance of comfort in service delivery selection. We recognise that the findings of this study are constrained by the fact that it was conducted in a single geographical region and utilised a small qualitative sample. While telepractice was successful in managing paediatric feeding disorders, further development and implementation of telepractice guidelines are needed for telepractice to be a viable service delivery option for families and children with feeding disorders.

Efficacy of telepractice, an alternative therapy tool during the coronavirus disease 2019 pandemic, for speech disorders related to congenital anomalies

Since telepractice regulation does not yet exist in Japan, we assessed telepractice efficacy and the level of satisfaction with telepractice versus that with face-to-face practice (FTFP) in speech therapy to establish effective telepractice in Japan. Changes in the number of therapy sessions and therapy levels were compared between telepractice and FTFP sessions conducted during the study period. Additionally, the patients' parents completed a questionnaire survey regarding telepractice. The mean number of sessions was not significantly different between the two types of therapy; the therapy levels, according to stepwise speech therapy, either increased or remained unchanged. The survey showed satisfaction with telepractice among all parents. Telepractice for cleft palate speech was delivered successfully with complete parental satisfaction.

Evaluation of a teleaudiology service in regional Australia

OBJECTIVE

Evaluate accessibility, effectiveness, acceptability and efficiency of a student- assisted teleaudiology model of care in a regional hospital in Queensland, Australia.

DESIGN

Prospective mixed method service evaluation study.

STUDY SAMPLE

Demographic, service and satisfaction data were collected from 233 patients (children aged ≥5 and adults) who received teleaudiology assessment. Satisfaction data was collected from 27 hospital clinic staff (medical, nursing and clinic assistants) and 28 university audiology clinical educator participants. Experience and satisfaction data were collected from 16 teleaudiology clinic university students. Quantitative data was analysed using SPSS software. Qualitative data were analysed using inductive content analysis.

RESULTS

Following introduction of the teleaudiology service in 2017 and evaluation during the first 6 months, 95% of patients were able to access audiology assessments on the same day as their Ear, Nose and Throat appointments. New referrals to the service were seen within a month. The audiology assessment battery was completed 95% of the time within an average of 33 minutes by the end of the study period. Patients, hospital and university staff and students reported high satisfaction with their experiences of teleaudiology, including its convenience and efficiency.

CONCLUSIONS

A student-assisted teleaudiology model of care can deliver accessible, effective, and efficient services with high levels of satisfaction by participants.

Amyotrophic Lateral Sclerosis-Bulbar Dysfunction Index-Remote: Test-Retest and Interrater Reliability of Candidate Items

PURPOSE

The primary aim of this study was to establish the reliability of candidate items as a step in the development of the Amyotrophic Lateral Sclerosis-Bulbar Dysfunction Index-Remote (ALS-BDI-Remote), a novel tool being developed for the detection and monitoring of bulbar signs and symptoms in remote settings.

METHOD

The set of candidate items included 40 items covering three domains: cranial nerve examination, auditory-perceptual evaluation, and functional assessment. Forty-eight participants diagnosed with ALS and exhibiting a range of bulbar disease severity were included. Data collection for each participant took place on Zoom over three sessions. During Session 1, the participants were instructed to adjust their Zoom settings and to optimize their recording environment (e.g., lighting, background noise). Their cognition and eating were screened to determine their ability to follow instructions and their eligibility to perform the swallowing and chewing tasks. During Session 2, two speech-language pathologists (SLPs) administered the tool consecutively to determine the items' interrater reliability. During Session 3, one of the SLPs readministered the tool within 2 weeks of Session 1 to assess test-retest reliability. The reliability of each item was estimated using weighted kappa and the percentage of agreement. To be considered reliable, the items had to reach a threshold of 0.5 weighted kappa or 80% percentage agreement (if skewed distribution of the scores) for both interrater and test-retest reliability.

RESULTS

In total, 33 of the 40 candidate items reached the reliability cutoff for both reliability analyses. All assessment domains included reliable items. Items requiring very good visualization of structures or movements were generally less reliable.

CONCLUSIONS

This study resulted in the selection of reliable items to be included in the next version of the ALS-BDI-Remote, which will undergo psychometric evaluation (reliability, validity, and responsiveness analyses). Additionally, the results contributed to our understanding of the remote administration of SLP assessments for telehealth applications.

Why do people who stutter attend stuttering support groups?

BACKGROUND

 Stuttering support groups (SSGs) have been a long-standing invaluable resource for people who stutter (PWS) but research into SSGs is only emerging. Speech-language therapists (SLTs) need further insight to successfully facilitate SSGs.

OBJECTIVES

 To determine PWS' perspectives regarding why they attend SSGs in South Africa.

METHOD

 Thirteen PWS who attend SSGs, between 20 and 58 years old, were a part of this qualitative study. Purposive sampling was utilised. Semi-structured telephonic interviews were used and data was analysed thematically.

RESULTS

 Four themes, namely, 'altered perceptions', 'increased sense of community', 'support group reciprocity', and 'support group environment, participants and topics', were identified. The results yielded clinical implications which included SLTs encouraging: (1) improved perceptions of being a PWS through education and self-empowerment, (2) PWS' connections between meetings to increase the sense of community, (3) reciprocity in meetings, (4) sharing personal stories to promote learning and general self-management and (5) support, praise and education to empower and encourage PWS. This study's findings show that SSGs helped PWS accept their stutter and gain confidence. This study showcased how SSGs can help PWS manage their fluency and gain confidence. Additionally, this study supports current research which suggests that dysfluency and social-emotional well-being should be equally addressed.

CONCLUSION

 Recommendations were generated from PWS' perspectives and included focusing discussions on fluency, emotions and sharing personal stories. Insights from PWS helped better inform SLTs of their role within SSGs including guiding and facilitating conversations.Contribution: People who stutters' perspectives can be used in clinical practice to help SLTs meet the needs of PWS and guide best practice when facilitating SSGs.

Barriers to Video Call-Based Telehealth in Allied Health Professions and Nursing: Scoping Review and Mapping Process

BACKGROUND

Telehealth interventions have become increasingly important in health care provision, particularly during the COVID-19 pandemic. Video calls have emerged as a popular and effective method for delivering telehealth services; however, barriers limit the adoption among allied health professionals and nurses.

OBJECTIVE

This review aimed to identify and map the perceived barriers to the use of video call-based telehealth interventions among allied health professionals and nurses.

METHODS

A comprehensive literature search was conducted in the PubMed and CINAHL databases on June 22, 2022, and updated on January 3, 2023, following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Only original studies published in English or German since June 2017 that reported barriers to the use of video call-based telehealth interventions were eligible for inclusion. The studies had to involve interviews, focus groups, or questionnaires with physical therapists, occupational therapists, speech and language therapists, audiologists, orthoptists, dieticians, midwives, or nurses. Each publication was coded for basic characteristics, including country, health profession, and target group. Inductive coding was used to identify the patterns, themes, and categories in the data. Individual codings were analyzed and summarized narratively, with similarities and differences in barriers identified across health professions and target groups.

RESULTS

A total of 56 publications were included in the review, with barriers identified and categorized into 8 main categories and 23 subcategories. The studies were conducted in various countries, predominantly the United States, Australia, the United Kingdom, Canada, Israel, and India. Questionnaires were the most commonly used evaluation method, with 10,245 health professionals involved. Interviews or focus groups were conducted with 288 health professionals. Most of the included publications focused on specific health care professions, with the highest number addressing barriers for physical therapists, speech and language therapists, and audiologists. The barriers were related to technology issues, practice issues, patient issues, environmental issues, attributions, interpersonal issues, policies and regulations, and administration issues. The most reported barriers included the lack of hands-on experience, unreliable network connection, the lack of technology access, diminished fidelity of observations and poor conditions for visual instructions, the lack of technology skills, and diminished client-practitioner interaction and communication.

CONCLUSIONS

This review identified key barriers to video call-based telehealth use by allied health professionals and nurses, which can foster the development of stable infrastructure, education, training, guidelines, policies, and support systems to improve telehealth services. Further research is necessary to identify potential solutions to the identified barriers.

Comparisons of Clients' and Caregivers' Satisfaction Across Conventional, Virtual, and Hybrid Speech-Language Therapy Services in Malaysia

Purpose

This study compared the satisfaction of recipients of conventional speech-language therapy (C-SLT), speech-language teletherapy (SLTT), and hybrid speech-language therapy (H-SLT), and determined sociodemographic factors that affect their satisfaction.

Patients and Methods

Participants were clients and caregivers of a speech-language clinic at a public university. Services were primarily provided by student clinicians, who were undergoing supervised clinical training. An online survey was distributed, which consisted of three sections: Background Information, Overall Satisfaction in SLT, and Satisfaction in SLTT. All participants completed the first two sections, while the third section was completed only by those who experienced SLTT or H-SLT.

Results

Most of the respondents were caregivers (89.7%), female (79.4%), of Malay ethnicity (80.9%), have received tertiary education (77.9%), within the low-income category (66.2%), held a job (76.5%), and resided in central West Malaysia (83.8%). Many participants experienced C-SLT (51%), followed by H-SLT (34%), and SLTT (15%). There were no significant differences in the overall satisfaction of the participants across three modes of services delivery (F[2,67] = 0.02, p = 0.95), and in the satisfaction with teletherapy between the H-SLT and SLTT groups (t = 0.90, p = 0.38). Income was the only sociodemographic factor that was correlated with the satisfaction level in teletherapy (r = 0.37, p = 0.04).

A Comparison of Voice Therapy Attendance Rates Between In-Person and Telepractice

PURPOSE

This study sought to investigate whether a significant difference exists in attendance, cancellations, and no-shows between in-person therapy and telepractice. The authors hypothesized that telepractice no-show and cancellation rates would be less than in-person no-show and cancellation rates.

METHOD

This retrospective study manually reviewed and analyzed attendance, no-show, and cancellation data over a 3-month span of in-person-only visits (September 2019-November 2019) and a 3-month span of telepractice visits (September 2020-November 2020) conducted at the Emory Voice Center, a tertiary care practice in urban Atlanta, Georgia. Additionally, data were collected for each patient's full course of therapy outside of the 3-month windows and analyzed for attendance, no-show, and cancellation patterns.

RESULTS

Data from 521 patients were available for review from the selected time frame. In 2019 (in-person), 157 patients met inclusion criteria, and in 2020 (telepractice), 176 patients were included. Therapy initiation, therapy attendance, and no-show rates had significant increases in the telepractice year, and cancellations made greater than 24 hr before the appointments had a significant decrease in the telepractice year. Furthermore, the overall course of therapy showed significantly fewer missed appointments and more attended appointments in the telepractice year.

CONCLUSIONS

Patients participating in voice therapy via telepractice are more likely to initiate treatment and attend treatment and less likely to cancel sessions compared with patients receiving treatment in person. These data combined with extant data on telepractice treatment efficacy indicate that telepractice should be considered standard of care and offered to all patients seeking treatment, as it removes many reported barriers to treatment.

Phase 1 of collaborative action around the implementation of virtual hearing aid care: Development of a clinical practice guideline

RATIONALE

There is a growing demand for comprehensive, evidence-based, and accessible clinical practice guidelines (CPGs) to address virtual service delivery. This demand was particularly evident within the field of hearing healthcare during the COVID-19 pandemic, when providers were faced with an immediate need to offer services at a distance. Considering the recent advancement in information and communication technologies, the slow uptake of virtual care, and the lack of knowledge tools to support clinical integration in hearing healthcare, a Knowledge-to-Action Framework was used to address the virtual care delivery research-to-practice gap.

AIMS AND OBJECTIVES

This paper outlines the development of a CPG specific to provider-directed virtual hearing aid care. Clinical integration of the guideline took place during the COVID-19 pandemic and in alignment with an umbrella project aimed at implementing and evaluating virtual hearing aid care incorporating many different stakeholders.

METHOD

Evidence from two systematic literature reviews guided the CPG development. Collaborative actions around knowledge creation resulted in the development of a draft CPG (v1.9) and the mobilisation of the guideline into participating clinical sites.

RESULTS AND CONCLUSION

Literature review findings are discussed along with the co-creation process that included 13 team members, from various research and clinical backgrounds, who participated in the writing, revising, and finalising of the draft version of the guideline.

Remote First-Language Assessment: Feasibility Study With Vietnamese Bilingual Children and Their Caregivers

PURPOSE

There is a shortage of bilingual speech-language pathologists (SLPs) in the United States. For Vietnamese, less than 1% of SLPs speak the language compared with a Vietnamese American population of > 2.1 million. This study examines the feasibility and social validity of remote child language assessment with the help of a caregiver to address the need for first language assessments among Vietnamese-speaking children.

METHOD

Twenty-one dyads of caregivers and typically developing children (aged 3-6 years) completed two assessment sessions in their first language, Vietnamese, using Zoom videoconferencing. Sessions were counterbalanced between two conditions in which either the clinician or the caregiver was the task administrator. Children's language samples were elicited using narrative tasks. Social validity was also assessed through caregiver and child questionnaires at the end of each session.

RESULTS

There were no significant differences between conditions on language sample measures nor the measures of social validity. Both caregivers and their children felt positively about the sessions. The caregivers' feelings were related to their perception of children's feelings about the sessions. Children's feelings were related to their Vietnamese language proficiency, caregiver-reported language ability, and whether they were born outside of the United States.

CONCLUSIONS

Findings build the evidence base for telepractice as an effective and socially valid service delivery model for bilingual children in the United States. This study supports the potential for caregivers as task administrators in a telepractice setting, making assessment in a child's first language more feasible and accessible. Future investigation is needed to extend results to bilingual populations with disorders.

Applications of Telemedicine in Speech-Language Pathology: Evaluation of Patient Satisfaction

OBJECTIVES

The study aimed to evaluate patient satisfaction with speech-language therapy televisits and to identify factors influencing the level of satisfaction.

METHODS

Participants were recruited from an academic tertiary voice and swallowing center who had completed ≥1 telehealth session of speech-language therapy with a speech-language pathologist between March, 2020 and April, 2021. Patient satisfaction was assessed using the Short Assessment of Patient Satisfaction (SAPS), a validated 7-item survey. Demographic characteristics of participants were collected from a review of patient charts.

RESULTS

65/239 patients completed the SAPS survey, representing a response rate of 27%. The average age of study participants was 54.92 ± 16.45 years, with 49.2% identifying as female, 33.9% as male, and 16.9% as trans-female. The mean SAPS score was 22.60 ± 3.89, with 84.62% of patients satisfied or very satisfied with their visit. Patients were most satisfied with provider respect (3.91 ± 0.34) and care received (3.74 ± 0.64), and least satisfied with visit length (2.32 ± 1.38) and explanation of treatment results (2.62 ± 1.72). Patient satisfaction was positively correlated with younger age and an increased number of televisits. Satisfaction did not differ significantly by gender identity, type of therapy received, insurance type, travel distance, or prior in-person therapy.

CONCLUSION

Clinicians are able to achieve high patient satisfaction with speech-language therapy when delivered by telehealth. Patient satisfaction remained high across diverse patient populations and range of clinical needs. Clinicians should remain cognizant of the unique limitations of older patients when conducting telehealth visits.

LAY SUMMARY

Clinicians are able to achieve high patient satisfaction with speech-language therapy when delivered via telehealth. Satisfaction remained high regardless of gender identity, type of therapy received, type of insurance, travel distance, or completion of prior in-person therapy.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:895-900, 2023.

Families' Experiences in the Virtual Hanen More Than Words Program During the COVID-19 Pandemic

PURPOSE

The COVID-19 pandemic required most pediatric rehabilitation programs to shift to a virtual delivery format without the benefits of evidence to support this transition. Our study explored families' experiences participating virtually in More Than Words, a program for parents of autistic children, with the goal of generating new evidence to inform both virtual service delivery and program development.

METHOD

Twenty-one families who recently completed a virtual More Than Words program participated in a semistructured interview. The interviews were transcribed and analyzed in NVivo using a top-down deductive approach that referenced a modified Dynamic Knowledge Transfer Capacity model.

RESULTS

Six themes capturing families' experiences with different components of virtual service delivery were identified: (a) experiences participating from home, (b) accessing the More Than Words program, (c) delivery methods and program materials, (d) the speech-language pathologist-caregiver relationship, (e) new skills learned, and (f) virtual program engagement.

CONCLUSIONS

Most participants had a positive experience in the virtual program. Suggested areas for improvement included the time and length of intervention sessions and increasing social connections with other families. Practice considerations related to the importance of childcare during group sessions and having another adult to support the videorecording of parent-child interactions. Clinical implications include suggestions for how clinicians can create a positive virtual experience for families.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.22177601.

Examining Use and Effectiveness of Teletherapy for Patients with Dysphonia

OBJECTIVE(S)/HYPOTHESIS

Virtual therapy (teletherapy) for patients with dysphonia has become ubiquitous in the COVID-19 era. However, barriers to widespread implementation are evident, including unpredictable insurance coverage attributed to limited evidence supporting this approach. In our single-institution cohort, our objective was to show strong evidence for use and effectiveness of teletherapy for patients with dysphonia.

STUDY DESIGN

Single institution, retrospective cohort study.

MATERIAL AND METHODS

This was an analysis of all patients referred for speech therapy with dysphonia as primary diagnosis from 4/1/2020 to 7/1/2021 and in whom all therapy sessions were delivered in a teletherapy format. We collated and analyzed demographics and clinical characteristics and adherence to the teletherapy program. We assessed changes in perceptual assessments and vocal capabilities (GRBAS, MPT), patient-reported outcomes (V-RQOL), and metrics of session outcomes (complexity of vocal tasks, carry-over of target voice) pre- and post-teletherapy using student's t test and chi-square test.

RESULTS

Our cohort included 234 patients (mean [SD] age 52 [20] years) residing a mean (SD) distance of 51.3 (67.1) miles from our institution. The most common referral diagnosis was muscle tension dysphonia (n = 145, 62.0% patients). Patients attended a mean (SD) of 4.2 (3.0) sessions; 68.0% (n = 159) of patients completed four or more sessions and/or were deemed appropriate for discharge from teletherapy program. Statistically significant improvements were seen in complexity and consistency of vocal tasks with consistent gains in carry-over of target voice for isolated tasks and connected speech.

CONCLUSIONS

Teletherapy is a versatile and effective approach for treatment of patients with dysphonia of varying age, geography, and diagnoses.

Comparison of In-Person and Online Recordings in the Clinical Teleassessment of Speech Production: A Pilot Study

In certain circumstances, speech and language therapy is proposed in telepractice as a practical alternative to in-person services. However, little is known about the minimum quality requirements of recordings in the teleassessment of motor speech disorders (MSD) utilizing validated tools. The aim here is to examine the comparability of offline analyses based on speech samples acquired from three sources: (1) in-person recordings with high quality material, serving as the baseline/gold standard; (2) in-person recordings with standard equipment; (3) online recordings from videoconferencing. Speech samples were recorded simultaneously from these three sources in fifteen neurotypical speakers performing a screening battery of MSD and analyzed by three speech and language therapists. Intersource and interrater agreements were estimated with intraclass correlation coefficients on seventeen perceptual and acoustic parameters. While the interrater agreement was excellent for most speech parameters, especially on high quality in-person recordings, it decreased in online recordings. The intersource agreement was excellent for speech rate and mean fundamental frequency measures when comparing high quality in-person recordings to the other conditions. The intersource agreement was poor for voice parameters, but also for perceptual measures of intelligibility and articulation. Clinicians who plan to teleassess MSD should adapt their recording setting to the parameters they want to reliably interpret.

Teleintervention for users of augmentative and alternative communication devices: A systematic review

AIM

To synthesize existing evidence on the effectiveness of speech-language teleinterventions delivered via videoconferencing to users of augmentative and alternative communication (AAC) devices.

METHOD

A systematic literature search was conducted in 10 electronic databases, from inception until August 2021. Included were speech-language teleinterventions delivered by researchers and/or clinicians via videoconferencing to users of AAC devices, without restrictions on chronological age and clinical diagnosis. The quality of the studies included in the review was appraised using the Downs and Black checklist and the Single-Case Experimental Design Scale; risk of bias was assessed using the Risk Of Bias In Non-Randomized Studies - of Interventions and the single-case design risk of bias tools.

RESULTS

Six teleinterventions including 25 participants with a variety of conditions, such as Down syndrome, autism, Rett syndrome, and amyotrophic lateral sclerosis met the inclusion criteria. Five studies used a single-case experimental design and one was a cohort study. Teleinterventions included active consultation (n = 2), functional communication training (n = 2), brain-computer interface (n = 1), and both teleintervention and in-person intervention (n = 1). All teleinterventions reported an increase in participants' independent use of AAC devices during the training sessions compared to baseline, as well as an overall high satisfaction and treatment acceptability.

INTERPRETATION

Speech-language teleinterventions for users of AAC devices show great potential for a successful method of service delivery. Future telehealth studies with larger sample sizes and more robust methodology are strongly encouraged to allow the generalization of results across different populations.

WHAT THIS PAPER ADDS

Individuals can learn to use augmentative and alternative communication (AAC) devices independently during tele-AAC interventions. Service providers and recipients reported an overall high satisfaction and acceptability for AAC services delivered via teleinterventions. Speech-language teleinterventions may be an effective method of providing AAC intervention services.

Vocabulary Acquisition and Usage for Late Talkers: The Feasibility of a Caregiver-Implemented Telehealth Model

PURPOSE

This feasibility study examined a caregiver-implemented telehealth model of the Vocabulary Acquisition and Usage for Late Talkers (VAULT) protocol. We asked whether caregivers could reach fidelity on VAULT, if the protocol was socially and ecologically valid, and if late-talking toddlers could learn new words with this model.

METHOD

Five late-talking monolingual and bilingual toddlers and four caregivers participated. The caregiver-related research questions involved measurements taken at multiple time points and replication across subjects but did not follow a specific research design. The toddler-related research questions included elements of a single-case design. Caregivers completed self-paced online training modules and then provided 8 weeks of VAULT to their children with remote coaching. Fidelity data were collected during coached sessions and through rating scales. Social and ecological validity data were collected via surveys and interviews. Children's word learning was measured before, during, and after treatment via production of targets and controls and via standardized vocabulary inventories.

RESULTS

Caregivers demonstrated high fidelity to VAULT throughout treatment. They reported being comfortable with many aspects of VAULT. Feedback was mixed regarding the time required. Many reported their child was talking more as a result of the program. Visual analysis revealed that toddlers learned more target than control words, which was corroborated by Tau-U and d effect size analyses.

CONCLUSION

A caregiver-implemented telehealth model of VAULT was feasible, was socially and ecologically valid, and benefited toddlers, making this a worthwhile model for future studies to examine.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21753872.

[Holistic semi-presential evaluation of oropharygeal dysphagia with the framework of International Classification of Functioning, Disability and Health: Optimizing evaluation to improve rehabilitation treatment]

INTRODUCTION

Oropharyngeal dysphagia can lead to medical complications and decreased quality of life. Although there is a wide diversity of instrumental and clinical procedures to assess it, consensus for its holistic evaluation is scarce and poorly defined. The objective of this article is to present the design of a model for the holistic examination of oropharyngeal dysphagia that takes into account the components of the International Classification of Functioning, Disability and Health (ICF) and that can be carried out both face to face and semi-presentially using Information and Communication Technology (ICT) tools.

MATERIAL AND METHODS

A non-systematic review of the literature is carried out in order to select validated oropharyngeal dysphagia assessment tools with the highest degree of recommendation. These tools are analyzed by a group of experts in oropharyngeal dysphagia from the Hospital de la Santa Creu i Sant Pau in Barcelona to design a holistic exploration model.

RESULTS

This evaluation model includes an assessment at the beginning and at the end of the treatment, as well as continuous monitoring during the rehabilitation process. It is implemented in a semi-presential and multidisciplinary way, and its purpose is to understand oropharyngeal dysphagia holistically to design and monitor an individualized therapeutic plan.

CONCLUSIONS

The evaluation of oropharyngeal dysphagia should be within the biopsychosocial framework proposed by the ICF. The application of ICT in blended interventions facilitates this.

Perspectives and performance changes of parents in aural-oral rehabilitation: From in-person to telepractice

INTRODUCTION

The coronavirus disease 2019 pandemic has reinforced the necessity and importance of telepractice. Although studies suggest frameworks to facilitate telepractice implementation, how parents learn related therapeutic skills via telepractice remains unexplored. The purpose of this study was to explore the perspectives and performance changes of parents with children enrolled in aural-oral rehabilitation who transition from in-person sessions to telepractice.

METHODS

A total of 456 parents were enrolled in an aural-oral rehabilitation program with different online session formats [telepractice (n = 392), consultation (n = 23), and hybrid (n = 41)] during the pandemic. The Parental Teaching Skil Scale and the Parental Behavioral Skills Scale were used to examine parent performance changes before and during the lockdown. Furthermore, semi-structured interviews were conducted with 10 parents.

RESULTS

Parents who scored higher in in-person courses were more likely to enrol in telepractice and make steady progress. Parents who participated in hybrid sessions tended to score lower on Parental Teaching Skill Scale before lockdown and reported that the dual-track, parallel learning method provided them with a set amount of time to discuss teaching difficulties with their therapists without being disturbed by their children. Parents who attended the consultation sessions scored higher on Parental Behavioral Skills Scale than on Parental Teaching Skill Scale during the in-person courses.

DISCUSSION

Parents who continued online courses during the lockdown showed consistent and significant gains in most skills related to aural-oral rehabilitation, regardless of session format. Moreover, parents who scored better on Parental Behavioral Skills Scale than in Parental Teaching Skill Scale during in-person courses tended to request consultation sessions during the lockdown.

Tele-rehabilitation in voice disorders during the pandemic: a consensus paper from the French Society of Phoniatrics and Laryngology

OBJECTIVES

To establish a consensus protocol for telerehabilitation in speech therapy for voice disorders.

METHODS

The study was conducted according to a modified Delphi method. Twenty speech therapist or laryngologist experts of the French Society of Phoniatrics and Laryngology assessed 24 statements of voice telerehabilitation with a 10-point visual analog scale ranging from 1 (totally disagree) to 10 (totally agree). The statements were accepted if more than 80% of the experts rated the item with a score of ≥ 8/10. The statements with ≥ 8/10 score by 60-80% of experts were improved and resubmitted to voting until they were validated or rejected.

RESULTS

The French Society of Phoniatrics and Laryngology experts validated 10, 6, and 2 statements after the first, second and third voting round, respectively. Seven statements did not reach agreement threshold and were rejected. The validated statements included recommendations for setting (N = 4), medical/speech history (N = 2), subjective voice evaluations (N = 3), objective voice quality measurements (N = 3), and voice rehabilitation (N = 5). The experts agreed for a follow-up consisting of combined telerehabilitation and in-office rehabilitation. The final protocol may be applied in context of pandemic but could be assessed out of pandemic period for patients located in rural regions.

CONCLUSIONS

This Delphi study established the first telerehabilitation protocol of the French Society of Phoniatrics and Laryngology for patients with voice disorders. Future controlled studies are needed to assess its feasibility, reliability, and the patient perception about telerehabilitation versus in-office rehabilitation.

Improving Functional Communication Outcomes in Post-Stroke Aphasia via Telepractice: An Alternative Service Delivery Model for Underserved Populations

Many persons with aphasia (PWA) have limited access to speech-language treatment (SLT) due to limited funding, speech-language pathologist shortages, geographical barriers, physical disabilities, transportation barriers, and the COVID-19 pandemic. The purpose of this study was to determine if telepractice is an effective and feasible service delivery model for PWA. Ten PWA completed 8 hours of remote treatment over 4 weeks. Synchronous telepractice sessions employed Oral Reading for Language in Aphasia (ORLA) and Conversational Script Training (CST). Pre- and post-assessment outcome measures included the Communication Activities of Daily Living-3 (CADL-3) and the Communication Confidence Rating Scale for Aphasia (CCRSA). Participants completed a telepractice satisfaction survey following post-assessment. All participants demonstrated improvements in CCRSA scores, total words produced correctly on trained CST stimuli, and total words produced correctly on trained ORLA stimuli. No differences were noted in CADL-3 scores. All participants were highly satisfied with telepractice as a service delivery model.

Supporting Emergent Bilinguals Who Use Augmentative and Alternative Communication and Their Families: Lessons in Telepractice From the COVID-19 Pandemic

PURPOSE

The purpose of this project was to examine the effect of the COVID-19 pandemic on speech-language pathologist (SLP) service provision for emergent bilinguals who use augmentative and alternative communication (AAC). One prominent issue in AAC service delivery is the efficacy and feasibility of providing AAC services via telepractice. The COVID-19 pandemic intensified this issue as most providers, clients, and families adjusted to remote service delivery models. While emerging evidence supports telepractice in AAC, little is known about the potential benefits and challenges of telepractice for emergent bilinguals who use AAC and their families.

METHOD

Data were collected via a nationwide survey. Licensed SLPs (N = 160) completed an online questionnaire with Likert-type, multiple-choice, and open-ended questions, analyzed using mixed methods.

RESULTS

Findings illustrated a shift in service delivery from in-person to telepractice and hybrid (both telepractice and in-person) models. Overall, child intervention outcomes declined for emergent bilinguals who used AAC during the COVID-19 pandemic, regardless of service delivery format. However, collaboration increased for many providers and families. Qualitative analyses highlighted barriers to AAC service provision for emergent bilinguals who use AAC that were exacerbated by the COVID-19 pandemic, as well as factors that facilitated collaboration and family engagement.

CONCLUSION

These findings suggest that, despite challenges, telepractice or hybrid services may be a promising approach to provide more culturally responsive, family-centered care for emergent bilinguals who use AAC.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20405673.

Healthcare Providers’ Perception and Barriers Concerning the Use of Telehealth Applications in Saudi Arabia: A Cross-Sectional Study

Background: Telehealth services are widely used in Saudi Arabia. Despite this, neither the use rate nor the attitudes, perceptions, and barriers concerning telehealth applications have been evaluated nationally from the perspective of healthcare providers (HCPs). Aim: This study aims to explore the use rate of telehealth, as well as the attitudes, perceptions, and barriers concerning telehealth use in Saudi Arabia from the perspective of HCPs. Methods and design: A cross-sectional survey was conducted and distributed to all HCPs between 16 November 2021 and 16 March 2022, through an online platform (Survey Monkey). Results: Overall, 1034 HCPs completed the online survey, of which 65.0% (n = 677) were male. Physicians accounted for 22.34%, while nurses and respiratory therapists accounted for 22.34% and 21.47%, respectively. Only 491 HCPs (47%) have used telehealth applications, the majority for less than a year (21.47%) or from one to three years (14.51%). Around 44% of HCPs perceived telehealth as being useful in quality and care delivery. Around 43% of HCPs felt comfortable using telehealth, and 45.45% perceived telehealth as being useful for patients with transportation difficulties. Additionally, 38% believed that telehealth provides a confidential way of protecting patients’ information, and 36% would like to receive more training in telehealth. Speech-language therapists and public health professionals were the highest HCP users (98% and 95%, respectively), while general physicians and dentists were the lowest users (44% and 55%, respectively). Lack of time or a busy schedule was the most common barrier to not using telehealth among all HCPs (38%). Conclusion: The use of telehealth was perceived as being positive as well as valuable and confidential in monitoring and providing care. However, challenges such as the lack of time or a busy schedule impeded the use of telehealth among HCPs in Saudi Arabia.

Provider and Patient Satisfaction with Telemedicine Voice Therapy During the COVID-19 Pandemic

OBJECTIVES

The COVID-19 pandemic expanded the use of telemedicine, but there is no literature exploring both patient and provider satisfaction specifically in the provision of voice therapy. This study aims to investigate patient and provider satisfaction with virtual voice therapy, its associated factors, and any correlation between the two.

METHODS

Cross-sectional study. Participants included 226 adults who underwent voice therapy delivered via telepractice at the USC Voice Center between April and October 2020. Patients and providers self-reported their level of satisfaction on a visual analog scale (VAS; range 0-100). Patient satisfaction was additionally measured using a previously validated Telemedicine Satisfaction Questionnaire (TSQ; range 1-5), and a binary question about their desire to choose telemedicine over in-person therapy in the future. Three speech-language pathologists rated provider satisfaction for all 226 patients. Patient satisfaction survey was completed by 55 patients. Multivariable linear regression analyses and linear mixed-effects models were used to assess the results.

RESULTS

Patient and provider mean (SD) VAS satisfaction scores were 86.8 (18.6) and 80.6 (19.7), respectively. The mean (SD) TSQ score was 4.4 (0.6). In a multivariable model, patient satisfaction levels were significantly higher for hypofunctional than for hyperfunctional dysphonia diagnoses. Forty-four (73%) patients reported they would prefer telemedicine voice therapy over in-person appointments, which was significantly correlated with internet reliability (P = 0.04). For providers, satisfaction was significantly lower for patients whose diagnosis had changed after initiation of voice therapy (Δ = -16.0 [95% CI: -28.7 to -3.2]) and for encounters with Asian patients compared to White patients (Δ = -11.6 [95% CI: -18.9 to -4.2]). Patient and provider satisfaction scores were weakly correlated (r = 0.19).

CONCLUSIONS

Our findings suggest that virtual voice therapy is not simply an alternative to in-person service, but rather an effective method useful beyond the current pandemic with proper diagnosis and technical support.

A Scoping Review of Technology and Infrastructure Needs in the Delivery of Virtual Hearing Aid Services

PURPOSE

The digital health revolution has brought forward integral technological advancements enabling virtual care as a readily accessible delivery model. Despite this forward momentum, the field of audiology still faces barriers that impede the uptake of virtual services into routine clinical practice. The aim of this study was to gather, synthesize, and summarize the literature around virtual hearing aid intervention studies and the related technology and infrastructure requirements.

METHOD

A scoping review was conducted using MEDLINE, CINAHL, Scopus, Nursing and Allied Health, and Web of Science databases. Objectives, inclusion criteria, and scoping review methods were specified in advance and documented in a protocol.

RESULTS

The 11 studies identified through this review related to virtual hearing aid services delivered by a licensed health care provider and/or facilitator(s) specific to hearing aid management, programming, verification, and validation services. Service delivery models varied according to patient population, technology experience, type(s) and time course of care, type of remote location, and technology/support requirements. Barriers and facilitators to implementation-related themes including technology access and function, client sociotechnical, convenience, education and training, interaction quality, service delivery, and technology innovation.

CONCLUSIONS

This scoping review provides evidence around the technology and infrastructure required for full integration of virtual hearing aid services into practice and according to care type. Low-tech versus high-tech requirements may be used to guide virtual service delivery triaging efforts. Research and development efforts in the areas of pediatrics, clinical support tools, and hearing aid/app-based solutions will support further uptake of virtual service delivery in audiology.

Knowledge, Attitudes, and Practices of Speech Language Pathologists in India about Telerehabilitation Services during the COVID-19 pandemic

PURPOSE

The global impact of the COVID-19 pandemic has opened opportunities for service providers and patients to continue with clinical services in certain extraordinary settings and circumstances. Telerehabilitation in the field of speech language pathology in India is still at its infancy, with a majority of the Speech Language Pathologists (SLP) accustomed with the conventional face-to-face system of service delivery. The present study aims to gather the knowledge, attitudes, and practices (KAP) of SLPs in India regarding telerehabilitation services during the pandemic.

METHODS

The study was conducted in three phases: phase I involved the development and validation of a questionnaire to explore the KAP of SLPs regarding telerehabilitation services. The items were framed based on a Likert rating scale (strongly agree, agree, neutral, disagree, and strongly disagree), yes-no-maybe format, open-ended, and multiple-choice format. Phase II involved data collection, while phase III involved data analysis. Descriptive statistics was done to derive the frequency and percentage for discrete variables and mean and SD for continuous variables.

RESULTS

Many SLPs feel underprepared in their technical knowledge and skills needed for telerehabilitation. Furthermore, a majority of the SLPs also did report patients to be relatively lesser motivated and satisfied with tele practices due to issues that are discussed in the paper.

CONCLUSION

This study is an initial attempt to touch upon the fabric of telerehabilitation services delivered by SLPs of India. Future studies are directed to study the technical, professional, and personal issues encountered during telerehabilitation services specifically pertaining to specific communication disabilities.

Caregiver Satisfaction with Delivery of Telehealth Autism Services

OBJECTIVE

The purpose of this study was to assess satisfaction with telehealth interventions for a large nonprofit organization that transitioned interventions for individuals with autism spectrum disorder (ASD) to telehealth during a pandemic. Services provided via telehealth included applied behavior analysis (ABA), speech and language, and occupational therapies. A secondary survey evaluated reasons for declining telehealth services.

METHODS

A survey was administered to 10,567 families who were receiving autism interventions. A total of 440 respondents answered all the questions on the survey, and their results were included in this study. A secondary survey was administered to 223 individuals who declined to have telehealth autism interventions.

RESULTS

There was not a clinically meaningful difference in satisfaction across service types. Although all ratings were in the high range, caregivers ranked speech therapists as more dependable than ABA therapists, and this difference was statistically significant. The findings suggested that the majority of caregivers were generally satisfied with services provided in a telehealth format. For those who declined services, the majority indicated a discomfort with the use of technology.

CONCLUSIONS

The participants of telehealth autism interventions reported high general satisfaction and indicated an improvement in their quality of life. Results provide suggestive evidence that increased satisfaction of telehealth services may allow for further acceptability and access for participants. Future research should evaluate participant and clinician satisfaction with telehealth versus in-person interventions.

FORUM: Remote testing for psychological and physiological acoustics

Acoustics research involving human participants typically takes place in specialized laboratory settings. Listening studies, for example, may present controlled sounds using calibrated transducers in sound-attenuating or anechoic chambers. In contrast, remote testing takes place outside of the laboratory in everyday settings (e.g., participants' homes). Remote testing could provide greater access to participants, larger sample sizes, and opportunities to characterize performance in typical listening environments at the cost of reduced control of environmental conditions, less precise calibration, and inconsistency in attentional state and/or response behaviors from relatively smaller sample sizes and unintuitive experimental tasks. The Acoustical Society of America Technical Committee on Psychological and Physiological Acoustics launched the Task Force on Remote Testing (https://tcppasa.org/remotetesting/) in May 2020 with goals of surveying approaches and platforms available to support remote testing and identifying challenges and considerations for prospective investigators. The results of this task force survey were made available online in the form of a set of Wiki pages and summarized in this report. This report outlines the state-of-the-art of remote testing in auditory-related research as of August 2021, which is based on the Wiki and a literature search of papers published in this area since 2020, and provides three case studies to demonstrate feasibility during practice.

Evaluating the Equivalence of Telepractice and Traditional Administration of the Test of Integrated Language and Literacy Skills

PURPOSE

This study evaluated the equivalence of the Test of Integrated Language and Literacy Skills (TILLS) when administrated via telepractice (Tele-TILLS) and face-to-face methods.

METHOD

Participants were 51 children and adolescents in three age bands, ages 6-7 years (n = 9), 8-11 years (n = 21), and 12-18 years (n = 21). Data were gathered by 25 volunteer examiners who assessed the same participants twice within a 2- to 4-week period, using Tele-TILLS and traditional methods in randomly selected, counterbalanced order.

RESULTS

Evaluation of identification equivalence showed 96% agreement between methods (49 of 51 decisions), with 39 agreements of no disorder, 10 agreements of yes disorder, and two disagreements (yes disorder for Tele-TILLS and no disorder for traditional). Partial correlations, controlled for test order, showed moderate to high agreement between all composite and subtest scores, except Nonword Repetition. Scoring by examiners and the first author showed high interrater agreement. No differences between Nonword Repetition scores were found for students who wore headsets (n = 12), whereas differences were found for those who did not (n = 34).

CONCLUSIONS

This study provided preliminary evidence that Tele-TILLS results can be equivalent to traditional TILLS, supporting its validity for identifying language/literacy disorder and interpreting profiles. The small, highly homogeneous sample with well-educated parents limits generalizability to the broader population. Caution is warranted when testing 6- to 7-year-old students for whom Nonword Repetition is part of the Identification Core score. Suggestions are provided for optimizing technological setup, preparing facilitators, and making minor modifications in subtest administration.

Can You See My Screen? Virtual Assessment in Speech and Language

PURPOSE

This introduction presents the LSHSS Forum: Can You See My Screen? Virtual Assessment in Speech and Language. The goals of the forum are to document reliability and validity of assessment results conducted virtually, identify characteristics of measures that are suitable for online assessment, and provide clinical and research guidance for interpreting diagnostic results obtained in virtual settings.

METHOD

In this introduction, we provide an overview of the research completed by nine teams, who submitted research articles and notes on a variety of topics pertinent to the theme of telehealth assessments. Of these, seven teams investigated the validity and reliability of 14 different assessment tools, while two teams described training and experience issues.

CONCLUSION

The nine studies presented in this forum will provide speech-language pathologists with insight into a range of issues regarding telehealth assessment, including the breadth of suitable assessment tools; practical strategies for assessing children with a diverse range of ages, languages, skills, and abilities; and the unexpected challenges and opportunities of conducting clinical work and research during a global pandemic.

Parent/Caregiver Views of the Effectiveness of Speech-Language Pathology for Children Born With Cleft Palate Delivered via Telemedicine During COVID-19

PURPOSE

The purpose of this study was to describe and examine parent views of speech-language pathology (SLP) for children born with cleft palate delivered via telemedicine during the COVID-19 pandemic in the United Kingdom (UK).

METHOD

Parents were asked whether they found this method of delivery "very effective," "somewhat effective," or "not at all effective." Free text was then invited. There were 212 responses. Ordinal chi-square, Kruskal-Wallis, or Fisher's exact tests examined associations between parent views of effectiveness and biological variables and socioeconomic status. Free text responses were analyzed using qualitative content analysis.

RESULTS

One hundred and forty (66.0%) respondents reported that SLP delivered via telemedicine was "somewhat effective," 56 (26.4%) "very effective," and 16 (7.6%) "not at all effective." There was no evidence of an association between parent reported effectiveness and any of the explanatory variables. Parent-reported challenges impacting on effectiveness included technology issues and keeping their children engaged with sessions. Importantly, telemedicine was viewed as "better than nothing."

CONCLUSIONS

Most parents reported that they felt SLP delivered via telemedicine during the first few months of the COVID-19 pandemic in the UK was at least "somewhat effective." It is important to interpret this in the context of there being no other method of service delivery during this time and that this study only represents families who were able to access SLP delivered via telemedicine. Further work is needed to identify which children with cleft palate might benefit from SLP delivered via telemedicine to inform postpandemic service provision.

From a Distance: Comparison of In-Person and Virtual Assessments With Adult-Child Dyads From Linguistically Diverse Backgrounds

PURPOSE

Our proof-of-concept study tested the feasibility of virtual testing using child assessments that were originally validated for in-person testing only.

METHOD

Ten adult-child dyads were assigned to complete both in-person and virtual tests of language, cognition, and narratives. Child participants fell between the ages of 4 and 8 years; adult participants were speech-language clinicians or researchers with experience in administering child assessments. Half of child participants were Spanish-English bilinguals, and half were monolingual English speakers.

RESULTS

Results showed similar performance across in-person and virtual modalities on all assessments. Recommendations for adapting, administering, and scoring virtual measures with linguistically diverse children are discussed.

CONCLUSIONS

Although additional research on virtual assessment is needed, our results open opportunities for appropriate remote assessment, particularly for bilingual children, who may not have in-person access to speech-language pathology services.

The neurogenic dysphagia management via telemedicine: a systematic review

INTRODUCTION

Telerehabilitation is the provision of rehabilitation remotely through Information and Communication Technologies (ICT). Recently, there has been an increase of interest in its application thanks to increasing a new technology. The aim of this systematic review was to examine the evidence of the literature regarding the management of neurogenic dysphagia via telerehabilitation, compared to face-to-face rehabilitation treatment. The secondary aim was to create recommendations on telerehabilitation sessions for patients diagnosed with neurogenic dysphagia.

EVIDENCE ACQUISITION

The databases were: Medline, Embase, CINAHL, Scopus. A total of 235 records emerged from bibliographic research, manual search of full text and from gray literature, published until January 2021. Two blinded authors carried out titles and abstract screening and followed by full-text analysis. Sixteen articles were included in the systematic review and assessed through critical appraisal tools.

EVIDENCE SYNTHESIS

The research shows that the majority of the studies on neurogenic dysphagia involved the Clinical Swallow Examination via telerehabilitation, compared with the in-person modality. Significant levels of agreement and high satisfaction from clinicians and patients are reported to support the use of telerehabilitation. Based on the results of this systematic review and qualitative analysis, the authors developed practical recommendations for the management of telerehabilitation sessions for patients with neurogenic dysphagia.

CONCLUSIONS

Despite the presence of barriers, telerehabilitation allowed healthcare provision and increasing access to care and services with specialized professionals, remote rehabilitation can be a valid resource during the health emergency due to COVID-19.

The unmet potential of artificial intelligence in veterinary medicine

Veterinary medicine is a broad and growing discipline that includes topics such as companion animal health, population medicine and zoonotic diseases, and agriculture. In this article, we provide insight on how artificial intelligence works and how it is currently applied in veterinary medicine. We also discuss its potential in veterinary medicine. Given the rapid pace of research and commercial product developments in this area, the next several years will pose challenges to understanding, interpreting, and adopting this powerful and evolving technology. Artificial intelligence has the potential to enable veterinarians to perform tasks more efficiently while providing new insights for the management and treatment of disorders. It is our hope that this will translate to better quality of life for animals and those who care for them.

Attitudes Toward Telehealth Services Among People Living With Parkinson's Disease: A Survey Study

Background

Telehealth has been widely adopted in providing Parkinson's disease care during the coronavirus disease 2019 pandemic.

Objective

The aim of this study was to survey people living with Parkinson's disease (PwPD) about their attitudes toward and utilization of telehealth services.

Methods

A survey was administered to PwPD via Parkinson's Foundation and Columbia University mailing lists.

Results

Of 1,163 responses, 944 complete responses were analyzed. Telehealth awareness was 90.2% (850/942), and utilization was 82.8% (780/942). More than 40% of PwPD were equally or more satisfied with telehealth compared with in‐person visits in all types of services used. The highest satisfaction was observed in speech‐language pathology appointments (78.8%, 52/66) followed by mental health services (69.2%, 95/137).

Conclusions

In selected circumstances and indications, such as speech‐language pathology and mental health services, telehealth may be a useful tool in the care of PwPD beyond the coronavirus disease 2019 pandemic. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson Movement Disorder Society.

Shades of Rage: Applying the Process Model of Emotion Regulation to Managing Anger After Brain Injury

Uncontrollable anger is common following an acquired brain injury (ABI), with impaired emotion regulation (ER) being one of the main contributors. Existing psychological interventions appear moderately effective, though studies typically include limitations such as small sample sizes, issues of long-term efficacy, and standardization of content. While ER has been a popular research field, the study of ER for anger management after ABI is less well investigated, and contains few interventions based on the widely used Process Model of ER. This review surveys the efficacy of ER strategies in individuals with ABI, and proposes a novel research design for future interventions. Recommendations are made about: strategy number and type, shared decision-making, approaches to data analysis, and mode of delivery.

Telepractice Considerations for Evaluation and Treatment of Voice Disorders: Tailoring to Specific Populations

PURPOSE

The aim of this clinical focus article is to provide recommendations for implementation of telepractice services for the evaluation and treatment of voice disorders and to use case examples to highlight the advantages of this modality of service delivery.

METHOD

In this clinical focus article, key factors for successful telepractice evaluation and treatment of voice and related disorders are discussed relative to clinical outcome measures. Case examples of telepractice voice therapy are described for a pediatric, transgender, and chronic cough client including associated acoustic, auditory-perceptual, and quality-of-life treatment outcomes.

RESULTS

Acoustic, perceptual, and quality-of-life outcome measures demonstrated functional voice improvements after treatment using the telepractice modality. The pediatric client showed decreased perceptual voice strain and increased speech intelligibility. The transgender client showed increased habitual speaking fundamental frequency (pitch) and quality of life. The chronic cough client showed improved vocal hygiene and reduced cough severity.

CONCLUSIONS

A review of the literature shows comparable outcomes for in-person and telepractice voice therapy, but special considerations must be made to ensure therapeutic success. We present three representative types of voice cases that illustrate implementation of voice evaluation and treatment using the telepractice modality. In all three cases, the clients' personal therapeutic goals were achieved without needing to travel to the clinic. Furthermore, asynchronous practice opportunities were found to be positive byproducts of using the telepractice modality.

[Teletherapy after cochlear implantation during the COVID-19 pandemic]

BACKGROUND

Due to the COVID-19 pandemic, digitalization in healthcare grew rapidly. Auditory training after cochlear implantation usually takes place face-to-face but social distancing interferes with this therapeutic approach.

MATERIALS AND METHODS

In follow-up treatment, 42 adult cochlear implant (CI) users aged 53.8 (±15.6) years received video therapy 1 x/week for 5 weeks on a certified platform. After each therapy session, the technical process and therapeutic content were assessed. At the end of the study, usability and the relationship between therapist and patient were evaluated by patients and therapists using the System Usability Scale (SUS), a final questionnaire and by the Skala Therapeutische Allianz - Revised (STA-R). Furthermore, a cost-benefit analysis was done.

RESULTS

Usability for both users was high (87.97 versus 93.0). Despite the lack of personal contact, therapeutic alliance was highly appreciated by patients and therapists (87.8% versus 84.8%). The main advantages for the patients were reductions in time and costs. In contrast, the rehabilitation center faced higher costs initially due to the longer time therapists needed to prepare the lessons. Technical problems had to be solved in > 75% of the first sessions but did not bother training thereafter. In total, 47.6% of the patients believe that teletherapy can completely fulfill their therapeutic needs.

CONCLUSION

Video therapy has been judged as a useful tool by all users and the majority wants to continue. However, it remains questionable whether the therapist-patient relationship can be sufficiently maintained over a longer period and whether online therapy is as effective as face-to-face therapy.

Parent engagement and therapeutic alliance in allied health teletherapy programs

Teletherapy services are being increasingly provided by allied health professionals to address major inequities of access. While clinical outcomes and stakeholder satisfaction are crucial for paediatric teletherapy's continued viability, processes for increasing parent/caregiver satisfaction, and for modifying aspects of caregiver engagement to improve outcomes, are under-researched. Studies of in-person therapy have shown that engagement, satisfaction and outcomes are influenced by the development of therapeutic alliance. This study investigates influences on parents' engagement with a teletherapy program and their therapeutic alliance with the therapist. Using a qualitative approach, data were analysed from semi-structured telephone interviews with six parents in rural New South Wales, whose children had completed paediatric teletherapy programs provided by a psychologist, speech pathologist or occupational therapist. Parents described factors that affected aspects of their engagement and alliance. Thematic analysis with constant comparison was used to determine the themes of the interviews, which were (a) initial engagement, (b) collaboration and (c) rapport. The themes demonstrate that parents were evaluating the efforts the therapists were making in (a) communicating, (b) truly partnering with them, both being elements of collaboration and (c) building rapport with them and the child. A conceptual model, Parent And Caregiver Evaluation Cycle In Teletherapy (PACECIT), is proposed by the researchers to explain how parents evaluated the therapist to judge the current state of a personal relationship and to judge the effectiveness of a collaborative relationship, both influencing the therapeutic alliance and motivation for engagement. The findings emphasise the importance of fulfilling parent/caregiver expectations for clear and frequent communication, and discussion of their ideas. Also important is the development of therapeutic alliance through utilising parents' observations of non-verbal communication to maintain an effective rapport and enhance engagement.