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JCPSLP
Volume 17, Number 3 2015
Journal of Clinical Practice in Speech-Language Pathology
consistent with previous findings of webcam delivery
treatment to a preschool population (Ciccia, Whitfird,
Krumm & McNeal, 2011). Ciccia et al. also reported that
participant families were highly satisfied with the low-tech
technology that was used.
Unexpected clinical observations made during webcam
delivery of the Lidcombe Program related to convenience,
clinical behaviour, treatment preparation, defining the
clinical space, behaviour management, and developing
relationships. Such observations are significant as a recent
review of peer-reviewed telehealth stuttering papers written
in the past 20 years stated that “clinical and technical
guidelines are urgently needed” (Lowe et al., 2014, p.
223). A literature review of paediatric speech and language
assessment efficacy and effectiveness concluded that
parent reports, clinical observations and details, and
technology procedures are not routinely reported in current
paediatric telehealth literature (Taylor, Armfield, Dodril &
Smith, 2014). Given the lack of precedent, or reported
clinical guidelines for working with preschool families via
webcam, the observations reported should be considered
by SLPs who engage in webcam SLP services with this
population. Specific recommendations are made following
the clinical observations reported in this paper.
Technological requirements
Potential families should have a computer and webcam,
with Internet that supports real-time audio and visual
connection. A pre-treatment webcam and Internet test is
recommended to confirm reliable and consistent Internet
connections exist prior to the first appointment.
Parent factors
It is recommended that the parent requirements for a
webcam consultation are explicitly discussed prior to
treatment. Parents should be informed what will be
expected of them in terms of preparing resources and
managing their child’s behaviour. More general discussion
of the parent’s behaviour management style and ability to
sustain their child’s attention may help to determine if
webcam is a suitable option. Such discussion also provides
transparency for the SLP. If expectations and requirements
are clearly discussed and agreed to initially, it may be easier
to engage in discussion addressing parent failure in
preparing or managing the child during the treatment
process.
Child factors
The greatest factor in a child’s compliance and participation
in webcam consultations was viewed to be the parent’s
ability to prepare the child and manage the child during
consultations. No other significant predictor variables or
traits were found in the subsets of children being more or
less likely to have successful webcam consultations
(Bridgman, 2014). Age and severity were not found to be
factors. In two cases, webcam children were given the role
of being responsible for the technology. This approach
seemed to appease these two children who were observed
to have a very “own agenda” presentation. It is
recommended that the child be given clear guidelines as to
what is expected of him or her also, and that a general
session structure is agreed upon and explained to the child
so that he or she becomes used to the consultation routine.
Such an approach could be based on the typical Stage 1
Lidcombe Program session sequence as detailed in the
current treatment guide (Packman et al., 2014, p. 10).
left unattended during a webcam consultation. These
instances raised the alert about a need to further develop
a contingency plan for such an occurrence, to protect the
SLP and further define duty of care. Possible contingencies
could include the SLPs stating that they will immediately
discontinue a call if a child is left unattended, abdicating any
responsibility for supervising the child, or stating that the
child is the sole responsibility of the parent for the entirety of
the consultation.
On a more positive note, the neutral treatment space
created by the online delivery allowed both parties to be
comfortable and safe in their own environments, supporting
the establishment of a balanced parent–SLP relationship.
Given the use of technology, the environment established
could be considered a “virtual” treatment space.
Webcam relationships
During the trial, parent questionnaires were used to elicit
parents’ views on how well rapport was developed with the
SLP via webcam. These reports seemed consistent with
what was experienced by the SLP. During the course of
Stage 1, webcam parents reported difficulties, spoke of
stressors, and demonstrated emotional responses during
these discussions. They often engaged in further discussion
of the challenges of treatment or life stressors affecting their
ability to apply treatment, or they expressed their fears and
concerns for their child who stuttered. At these moments,
the parent would dismiss the child from the room, start the
consultation without the child, or wait until the consultation
was finished so that they could direct the child to another
activity. Such discussions were viewed by the SLP as part
of the problem-solving element of the Lidcombe Program
treatment process. In allowing the parent to communicate
those feelings and discuss in detail and length the
challenges or emotions, the SLP could then support the
parent and adapt the program accordingly.
During initial consultations, the webcam children often
asked where the SLP was physically located. As the
consultations progressed, and the children became familiar
with the consultation routine, they asked eagerly what
resources the SLP had to share with them. Furthermore,
the children often prepared their own resources and
were also more likely to relate the SLP’s comments or
questions to items they had in their home, leaving the
computer to source the desired item. Clinic children
rarely bought personal items from home to share with
the SLP during clinic consultations. These observations
support the individualisation of the Lidcombe Program as
recommended in the standard treatment guide, as it also
allows the SLP to better know and understand the child’s
interests and everyday life. The webcam delivery also
helped the SLP to establish relationships with other family
members who often greeted her when walking past the
computer.
Discussion
Given the non-inferiority finding of the RCT comparing
webcam delivery of the Lidcombe Program with standard
clinic delivery, clinical translation may now be feasible and
appropriate given that Speech Pathology Australia:
“supports the use of telepractice … where telepractice is
based on current evidence-based practice and is at least
equivalent to standard clinical care” (Speech Pathology
Australia, 2014, p. 5). Such positive reception of webcam
treatment received by metropolitan-based families is