JCPSLP Vol 17 No 3 2015

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

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).

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JCPSLP Volume 17, Number 3 2015

Journal of Clinical Practice in Speech-Language Pathology