Rethinking your approach
Telepractice presents challenges and opportunities for engaging with children. As you develop your telepractice approach, consider what methods will best support the parent and child to achieve the best outcomes.
Telepractice presents challenges for engaging with children – for example, getting them to focus on the screen of the device, maintaining their attention on the device, difficulty prompting the child effectively through the screen, need for an adult to be present on the other end to manage the technology, children being uncomfortable with equipment, e.g. wearing headphones (Arefadib & Moore 2017).
Parent-mediated interventions refers to when a practitioner seeks to support a child by teaching the child’s parent(s) or other caregiver(s) how to act as the child’s intervention provider. The parent can act as the practitioner’s local ‘accomplice’ carrying out elements of the intervention with the coaching and supervision of the remote practitioner.
Advantages of a parent-mediated approach
A parent-mediated approach helps manage issues such as the practitioner not being physically present and child engagement. It drives practitioners to help parents build skills that they can use to support their child in the long term, rather than applying the skill themselves and expecting the parent to learn it just by watching.
The parent-mediated approach is more naturalistic – the child need not be taken out of their natural environment to deliver the intervention.
Parent-mediated interventions are well-supported by a significant scientific evidence base.
Using parent-mediated approaches
Practitioners should select practices that work well as parent-mediated interventions and consider whether there are practices you can adapt to be parent-mediated rather than delivered directly to the child. Practitioners could consider using this approach when working to support a wide range of issues, such as:
- behavioural issues, including Oppositional-Defiant Disorder
- speech and language
- early childhood intervention
- Autism Spectrum Disorder
- child mental health
- Attention Deficit Hyperactivity Disorder.
The below five steps explain how practitioners who would traditionally deliver services directly to children can adapt their practices to a parent-mediated approach, via telepractice. It is relevant to practitioners across family services, early intervention and allied health. We have adopted a framework for parent-mediated intervention developed by Snodgrass et al. (2017).
Step1: Identify target skill
- Early in your engagement with a family, undertake one or more assessments to identify the family’s goals for their child.
- Identify target skills that are likely to contribute towards those goals (e.g. a goal of “less fighting in the home” might be supported by the child developing new self-regulation skills, or behaviours to get their needs met).
- Break this down into one or more descriptions of concrete, observable behaviour that can be readily identified by both the parent and the practitioner.
Step 2: Identify target strategy
- Choose an evidence-based strategy that is likely to support the development of the target skill. This strategy should be agreed upon by both the practitioner and parent.
- Practitioners may draw on their own training and clinical experience to identify suitable, evidence-based strategies. A range of such strategies can also be found at raisingchildren.net.au.
Step 3: Create parent-friendly procedures
- Parents may find it challenging to understand and apply some strategies consistently. To help, translate the strategy into two aims: 1) make it simple, clearly described, and as easy as possible for the parent to remember; 2) it needs to be actionable and adapted to the parent’s life and circumstances so that it fits in with their routines, resources and preferences.
- It may help to develop simple and illustrative supporting materials (e.g. illustrated handouts or step-by-step videos).
Step 4: Teach the parent
- Present the overall process first so that parents can take in what’s involved, then walk them through each step.
- Consider which elements the parent might be able to learn from resources such as articles or videos, that they can access asynchronously, and what is best done through direct contact with you over videoconference.
- Generally, videoconference might be better for providing practice opportunities to the parent, because you can offer scaffolding and feedback.
Step 5: Coach the parent to mastery
- Ideally, seek opportunities to observe the parent’s application of the strategy with their child. This could involve selecting a suitable activity for the parent and child to do together while you’re present during a videoconference session, or the parent could record the interaction and share with you via a file sharing platform (e.g. Google Drive, WhatsApp). Guide the parent on how to set up their device so that you will have a wide enough view to see both parent and child (for example, by propping the phone against some furniture or a few books, or making a makeshift phone tripod out of a paper cup).
- Conduct a post-observation debrief/reflection session with the parent. Prompt them first to reflect on their application of the strategy and their child’s progress towards demonstration of the skill. Then provide your observations about what worked well, plus any opportunities you identified to enhance their application of the strategy.
- Continue to schedule observation and coaching sessions until mastery is achieved. Practitioners and families can choose to target the child’s mastery of the skill, or the parent’s mastery of the strategy (with the understanding that the parent will continue to apply the strategy to support the child’s progress towards mastery). The practitioners should continue to check in occasionally about the child’s use of the skill and the parent’s use of the supporting strategy, while circling back to the start of the flow chart to select a new target skill.
These examples are simplified to concisely reflect the parent-mediated approach. We acknowledge that practitioners working with families are generally juggling many more variables than those presented here.
These examples don’t cover the essential practices required for setting up telepractice sessions with families. Practitioners who would benefit from this may wish to view other resources on this website. Alternatively, the NSW Agency for Clinical Innovation has produced a useful guide.
Louis is a ten-year-old with additional needs whose family is experiencing disadvantage. Louis has been displaying significant behavioural issues at home and at school. Social worker Irma has been working with Louis to help him understand and process his emotions, which she has identified as contributing to his behavioural outbursts. She has been doing this face-to-face, however, recently Louis and his mother, Dominica, have moved residence to live with a relative due to financial issues, and they are now too far away for Irma to provide services face-to-face.
Irma has tried continuing her sessions with Louis via videocall, but found that he quickly becomes distracted and even leaves the room partway through the session. Because of this, Irma decides it may be appropriate to switch her approach to a parent-mediated intervention for Louis’s behaviour issues. After reviewing the case notes and consulting with her supervisor, Irma has a discussion with Dominica about the parent-mediated approach. Dominica is very willing to try the approach, but notes that financial stress may impact her ability to apply strategies. They agree to undertake the approach on a trial basis.
- Step 1: Identify target skill
Based on her understanding of the literature on behaviour management, Irma suggests that a good target skill for Louis to develop could be the ability to express when his mood is becoming heightened, so that those around him can respond to de-escalate the situation before a behavioural outburst eventuates. Dominica also feels this would be a fantastic outcome to achieve. Irma, Dominica and Louis workshop the idea and express the target behaviour in concrete terms: “When Louis notices that he’s becoming frustrated, he will tell someone he’s with ‘I need to take a break’, and if prompted, give them a SUDS (Subjective Units of Distress Scale) rating out of 10.”
- Step 2: Identify target strategy
Dominica and Irma decide that Dominica can be effective in supporting Louis’s development of this skill through prompting him regularly. They involve Louis in the discussion and together they identify that this is particularly important in certain situations like getting ready for school in the morning and after dinner in the evenings, because Louis is more likely to get agitated at these times and is also less likely to remember to apply the target behaviour (expressing his heightened mood).
- Step 3: Create parent-friendly procedures
Because of everything else going on in her life, Dominica identifies that she will need help to apply the strategy. Irma helps design a number of measures to help her with this. She prepares a ‘poster’ featuring the identified skill for Louis and the support strategy that Irma should apply, including vivid colours to catch the eye, for the family to post in a prominent position (such as the fridge door). She helps Dominica identify key times of day when she might apply the prompting strategy, based on Dominica’s routines. She also holds a videocall session with Dominica to go through setting up regular reminders on Dominica’s phone to apply the strategy of checking in with Louis.
- Step 4: Teach the parent
Although the strategy itself is relatively simple, Dominica and Irma identify that the wording is important if it’s to help de-escalate Louis’s mood. They also acknowledge that Dominica tends to get ‘worked up’ herself when Louis’s mood escalates, so she needs to develop her self-management skills. Dominica and Irma hold weekly practice sessions where Dominica describes recent experiences of trying to apply the strategy with Louis, and Irma also presents some role-play scenarios for Dominica to rehearse her approach.
- Step 5: Coach the parent to mastery
Louis agrees to participate in a weekly videocall with Irma, alongside Dominica. Although these can sometimes devolve into arguments between Louis and Dominica, Irma uses this as an opportunity to coach Dominica in the use of the strategy. After eight weeks, Irma notes that Dominica is significantly more patient with Louis’s outbursts, and Louis is reliably expressing his frustration through words, even having adapted the wording to suit him (“You’re pushing me to 7 out of 10 right now”). In consultation with her supervisor, Irma decides that the family can apply the skill and supporting strategy consistently, so moves on to identifying a new skill to target, while continuing to check in regularly on how they’re going with the expressing frustration skill.
An early intervention Key Worker, Jo, has taken on a newly enrolled family – Mari and her parents Elle and Robin. Mari has a developmental delay and her family is keen to support her cognitive, language and social development. The family has expressed a strong preference for telepractice due to busy work schedules and the need to care for two other children with additional needs. Because Mari is only three, Jo believes that a parent-mediated intervention is the best approach in this case. She discusses this option with Elle and Robin over the phone and they agree that this would be beneficial.
- Step 1: Identify target skill
Jo discusses current needs and concerns with Elle and Robin. She discovers that Mari is speaking only one or two words, and although she makes a range of other noises they’re not intelligible as words. Together they decide that a worthwhile aim would be to increase the amount of words that Mari uses. Based on the family’s observations, they agree that good areas to focus on would be words around mealtimes like “eat,” “more” and “ta” (please/thank you). Jo helps them put this in concrete terms as “at mealtimes, Mari will say words recognisable as “eat”, “more” and “ta” in a way that corresponds to their meaning.”
- Step 2: Identify target strategy
Jo’s expertise in early intervention leads her to believe that Mari’s parents can support her use of this skill by using these words in a particular way themselves. She suggests to Elle and Robin that she can teach them a routine involving identifying situations where each word is relevant, making good eye contact with Mari, saying the word in a loud, clear voice while emphasising the articulation with their lips, and waiting expectantly for Mari to make a response. They identify another strategy based on recognising Mari’s attempts at communication, asking if she means the word they suspect and saying the word while waiting expectantly for her to say it.
- Step 3: Create parent-friendly procedures
In consultation with Elle and Robin, Jo has chosen to target mealtimes for this parent-mediated intervention because it fits best with the family’s routines – Mari usually has at least one parent’s attention for about 20-30 minutes at mealtime, so it is realistic for them to try to apply the strategy within this window. It’s also relatively structured so it’s easier for Elle and Robin to recognise the situations when they should be using the strategy.
- Step 4: Teach the parent(s)
Based on her previous experience, Jo recognises that the strategy identified can feel unnatural to parents who aren’t familiar with interacting with young children in this way. To make the procedure more parent-friendly, she collects a list of supporting materials including video demonstrations available on YouTube and a brief pictorial guide that can be viewed on a smartphone.
Jo sets up a series of weekly videocall sessions where she guides Elle and Robin through the approach. She continuously reminds them of the two relevant strategies and explains each step. She gives them opportunities to roleplay with her.
- Step 5: Coach the parent(s) to mastery
Jo asks the family to film one mealtime (or more) per week. She discusses with them how they can do this on their smartphones. Because the video needs to capture the whole breakfast table, they find a position where the phone can be propped up on a nearby bookcase at eye-level. They use a system where the recording is then uploaded to Google Drive because the file is too large for the family’s email system. Jo reviews the video then holds a videocall with both parents to discuss. She provides positive feedback on multiple features of how they interacted with Mari in the video. She also provides one or two suggestions for things that they could use to enhance their use of the strategy they’re applying.
After four weeks of focusing exclusively on this procedure, Jo feels confident that Elle and Robin have mastered the strategy to help Mari learn the target language skill. Because it may take a while for Mari to master the skill, the family agrees with Jo that they can add in another target skill and support strategy to work on while they continue their focus on “eat, “more” and “ta” at mealtimes. Jo initiates the process for the new skill back at Step 1: Identify target skill.