Speech-language pathologists’ practices and perceptions of parent involvement in paediatric services funded by the NDIS in Australia

Abstract

Purpose: There has been concern that a shift in disability funding to the National Disability Insurance Scheme (NDIS) in Australia may have influenced paediatric speech and language intervention to involve parents less in service delivery. This study aimed to describe paediatric speech-language pathologists’ (SLPs) practices and perceptions of parent involvement in NDIS-funded speech and/or language intervention.

Method: Seventy-two paediatric SLPs currently practicing in Australia with NDIS-funded speech and/or language clients completed an online survey. The survey assessed SLPs’ self-reported practices supporting parent involvement through Likert scale responses and included open-text questions about perceived barriers and facilitators in NDIS-funded intervention services. Results from the survey were analysed using descriptive statistics, significance testing, and thematic analysis.

Result: The majority of SLPs indicated commitment to involving parents in intervention. Experienced SLPs used more family-centred practices and Department of Education (DE)-based SLPs used fewer. Barriers arose from SLP, parent, and workplace characteristics. Facilitators included communication and rapport building, utilising a family-centred model of service delivery, and parent characteristics.

Conclusion: This self-selected sample of Australian SLPs utilised many techniques to facilitate parent involvement within NDIS-funded paediatric speech and language intervention. Results indicate NDIS-funded SLP services for families are family focused.

Keywords:

• NDIS funding
• parent involvement
• speech-language pathology
• service delivery
• speech intervention
• language intervention

Introduction

Family-centred service delivery models

Families play a crucial role in intervention for children with speech and language disorders, due to their knowledge of their child’s characteristics and how the communication disorder presents limitations to activity and participation. On the continuum of practice, utilising parent¹ involvement in intervention is located towards the family-centred end of the spectrum (McKean et al., 2012). Family-centred intervention services are defined as primary expert guidance by the speech-language pathologist (SLP) and implementation and assistance by parents (Watts Pappas & McLeod, 2009). In recent decades, SLPs have changed how they work with families, shifting from a therapist-centred model with limited parent involvement where the SLP solely provides skilled intervention to clients directly (DeVeney et al., 2017), to family-centred models where parents are more considerably involved in the intervention process (Watts Pappas & McLeod, 2009). SLPs have expressed the importance of a range of family-held characteristics that align with parent involvement in early speech-language pathology intervention, such as having an open and honest relationship with the SLP, being reliable and prepared for intervention, and investing in intervention at home (Melvin et al., 2021). Parent involvement in intervention has been shown to benefit children’s development (DeVeney et al., 2017). Despite this, research on the contexts of collaboration, the mechanisms of change, and the impact on the child’s outcomes is scarce. The shift in the disability funding structure in Australia to the National Disability Insurance Scheme (NDIS, 2020), a consumer-centric funding model with a focus on participant choice and control, may have influenced paediatric speech and language intervention away from utilising family-centred service delivery models. The current study therefore explores parent involvement within NDIS-funded paediatric speech-language pathology services.

Barriers to and facilitators of parent involvement

Barriers to parent involvement commonly occur within provision of speech and language intervention, even when parents desire to be involved (Watts Pappas et al., 2008). These barriers may relate to parents, SLPs, or workplace constraints. SLPs can face parent-related barriers of parent capability to attend sessions (Sugden et al., 2018). In addition, parents do not always see it as their role to provide intervention outside of the clinic (Sugden et al., 2018), and parents may experience difficulties in completing home practice with their children (Watts Pappas et al., 2016).

Barriers arising from SLPs themselves can include a lack of confidence to train parents in providing intervention (Sugden et al., 2018). As a result, while SLPs may hold strong beliefs on incorporating parent involvement into their practice, this may not always lead to parent involvement being a part of their service delivery (Watts Pappas et al., 2008). SLPs are also subject to time constraints, which may limit parent involvement (Mandak & Light, 2018).

Workplace barriers may also impede desired levels of parent involvement. Parents may not be able to attend sessions in school settings at a level conducive with desired levels of parent involvement (Sugden et al., 2018). Mandak and Light (2018) reported on school-based SLPs’ practices and beliefs regarding family-centred services for children with complex communication needs. Barriers were found to arise from a lack of time and a high level of scheduling challenges.

Service features that facilitate parent involvement include discussing how therapy goals can transfer into the child’s day-to-day life, and helping parents understand specialised knowledge typically held by SLPs (Egilson, 2011). Parents also believed increased collaboration among key stakeholders of the child alleviates the need for themselves to act as the mediator, allowing themselves to be more available to provide indirect supports (Egilson, 2011).

Evidence for parent involvement in speech and language intervention

SLPs utilising family-centred service delivery models should consider how parents view their roles and how they prefer to be integrated within the intervention process. While parents initially assume the role of advocacy for their child when seeking disability funding and subsequent support services (Glogowska & Campbell, 2004; McAllister et al., 2011), parents may feel uncertain about their role once intervention is underway. Parents often consider the SLP to be the fixer of problems in the intervention process (Carroll, 2010; Watts Pappas et al., 2016), thus they may adopt non-intrusive roles of observer within sessions and implementer of home activities outside of sessions (Watts Pappas et al., 2016). Including parents in the planning stage may allow negotiation of the role parents are to play in intervention, which can lead to an increase in both parents’ satisfaction of the intervention and engagement with services (Glogowska & Campbell, 2004).

Some studies have suggested parents prefer SLPs to hold the primary decision-making role in family-centred models of practice (Carroll, 2010), viewing their involvement as a supporter of intervention as “the most efficient way to utilise a finite service” (Watts Pappas et al., 2016, p. 236). However, parents in these studies may not be fully aware of the option of family-centred care and how they can hold a primary role in the formatting of intervention. Thus, SLPs have a responsibility to discuss these possibilities fully with each family so that informed decisions can be made (Carroll, 2010).

Provision of intervention for children with speech sound disorders (SSDs) is a core clinical role in the work of paediatric SLPs, as children with SSDs comprise nearly half of a typical caseload in Australia (McLeod & Baker, 2014). Research suggests there is misalignment between effective levels of intensity of SSD intervention in research studies and the intensity of day-to-day clinical practice (McLeod & Baker, 2014; Sugden et al., 2018). As SLPs face barriers of time and capacity to deliver recommended levels of intensity in service delivery, assisting parents to conduct home practice outside of clinic is a reasonable way to extend time spent on intervention (Sugden et al., 2018).

The number of SLPs reporting parent involvement in intervention sessions for SSDs within Australia has increased over time from 35% (Watts Pappas et al., 2008) to 89% (Sugden et al., 2018). While wording differences between relevant survey questions in these studies may have influenced participant responses, findings from these studies may indicate an increasing trend of SLPs involving parents in SSD intervention. Parents’ changing opinions may have influenced this shift, as parents of children with SSDs in recent studies reported their involvement in intervention to be vital (Watts Pappas et al., 2016).

Presence of an association between characteristics of SLPs and their involvement of parents in intervention for children with SSDs has been identified (Joffe & Pring, 2008; Oliveira et al., 2015). SLPs who were more experienced were reportedly less likely to give parents the opportunity to make final decisions about goals for their child’s intervention (Watts Pappas et al., 2008) and more likely to use a wider variation of parent-training methods and training in more areas of SSD intervention (Sugden et al., 2018). School-based SLPs were reportedly less likely than SLPs practising in other work settings to provide parent training and have parents attend sessions (Sugden et al., 2018; Tambyraja et al., 2017), and to encourage parents to complete home practice in SSD intervention (Tambyraja, 2020; Tambyraja et al., 2017). They were also reported to have fewer interactions with parents and to interact with them on a more variable frequency (Tambyraja et al., 2017).

The body of literature exploring parent involvement in language intervention is more limited compared to research exploring parent involvement in SSD intervention. Roberts and Kaiser (2011) have identified that strengthening parent skills for teaching language in parent-child interactions is a common method of indirect service delivery for language intervention for young children. However, studies within this meta-analysis largely focused on parent-led intervention programs such as the It Takes Two To Talk Hanen Program (Pepper & Weitzman, 2004) and minimally on more simplistic approaches to extend dosage or exposure to language interventions, such as SLPs providing home activities.

Speech-language pathology under the NDIS

Australia’s NDIS is a consumer-centric funding model that aims to deliver increased choice and control of funding to parents of children with disabilities. Previous models of disability funding used by the Australian government were seen as underfunded, fragmented, and inefficient (Commonwealth of Australia, 2011). These weaknesses impacted those seeking services, by limiting choice and guaranteed access to necessary and appropriate supports. The National Disability Insurance Scheme Act (2013) established the nationwide rollout of both the NDIS and the representative managerial body, the National Disability Insurance Agency (NDIA), from 2013. Access to the provision of early intervention support through the NDIS is open to children under 6 years of age who have a developmental delay (NDIS, 2022). The intention of early intervention is to “alleviate the impact of a person’s impairment on their functional capacity by providing support at the earliest possible stage” (NDIS, 2020, Access to the NDIS—Early intervention requirements, para. 1).

The Australian government developed the NDIS based on the concept of marketisation of individual disability support services. This shift allows individuals with NDIS funding to hold more autonomy over choice of supports and providers they deem beneficial. Increasing the decision-making power of parents whose children are NDIS funded may influence parent choices in their involvement in their child’s intervention.

Minimal literature has explored the response of SLPs adapting their service provision. Foley et al. (2021) explored the complexities experienced by disability service providers transitioning to the NDIS-funding model. They reported the transition to a more business-centric model of service provision led SLPs to develop business and administration management skills and identified that some providers reported increased bureaucracy that impacted their capacity to optimise client outcomes. The shift towards a business model means SLPs must consider financial viability when providing intervention services to NDIS participants. For example, whether satellite services, such as correspondence with parents outside of clinic hours, are feasible if these are not billable hours. Therefore, this assumed change to provide only remunerable services may steer intervention away from the utilisation of family-centred models.

Study aims and research questions

Little is known about how the NDIS has influenced Australian SLPs’ service delivery. It is possible the shift to a business model of funding may have unintended negative impacts on parent engagement in speech-language pathology intervention for children. Furthermore, information on how parents and SLPs collaborate in speech-language pathology services for children with speech/language needs is scarce. This research therefore sought to explore SLPs’ practices in Australia relating to NDIS-funded parent involvement in speech and language intervention by addressing the following questions:

1. Do SLPs working with children who are funded by the NDIS report the use of practices that aim to facilitate parent involvement?

2. What SLP characteristics influence parent involvement in speech and/or language intervention funded by the NDIS?

3. What barriers or facilitators do SLPs perceive in parents’ involvement in speech and/or language intervention funded by the NDIS?

Method

Research design

This study used a mixed-methods descriptive research design (Fritz & Lysack, 2020; Portney, 2020). It used an anonymous online survey to collect qualitative and quantitative data from Australian SLPs on their parent-involvement practices in their interventions funded by the NDIS for children with speech and/or language disorders. This study was approved by the Human Ethics Committee at the University of Canterbury (HEC-2020/10/LR).

Survey description

The survey instrument was created based on surveys utilised in Watts Pappas et al. (2008) and Newbury and Sutherland (2020), using the Qualtrics survey creation platform. The survey comprised 46 questions using multiple choice, open text, and Likert scale response formats. The questions gathered information on: (a) participant demographics (Questions 1–4; multiple choice format); (b) participants’ caseloads and service delivery (Questions 5–9; multiple choice format); (c) participants’ involvement of parents in children’s NDIS-funded speech and/or language intervention (Question 10; Likert scale statements); (d) demographic and clinical data of one to three most recent NDIS-funded clients with speech and/or language needs (Questions 11–16, 23–28, 35–40; multiple choice format); (e) participants’ strategies used to involve parents in intervention for those clients (Questions 17–20, 29–32, 41–44; open text format); and (f) participants’ perceptions of barriers and facilitators that influence parent involvement in intervention for these clients (Questions 21–22, 33–34, 45–46; open text format). Note for section (d) the second and third clients were optional for the first 16 of 72 participants then, due to low completion rates, were subsequently deleted from the survey. Therefore there is data on one to three clients per participant available for a total of 106 clients. As questions relating to the second and third clients were optional, some questions for these clients were missed by participants. The survey is available as Supplementary Material.

Participant recruitment

Targeted participants were SLPs currently practising in Australia who conduct speech and/or language intervention with children funded by the NDIS. Three recruitment channels were utilised to distribute the survey: an advertisement placed in Speech Pathology Australia’s monthly eNewsletter over 3 months, Facebook groups relating to NDIS service delivery, and the research team’s professional networks. Data collection took place between August and October 2020. Participation was voluntary, with consent deemed to be given if a completed survey was submitted. Partially completed and unsubmitted surveys were not included in the data.

In total, 105 SLPs accessed the survey and 72 (69%) submitted a completed survey. Data from the 33 SLPs who did not complete or submit the survey were not included in the data analysis. Participants were also able to access a prize draw survey following submission. This survey was not linked to information participants provided in the initial survey, thus anonymity could be maintained. Of the 72 participants who submitted a completed survey, 55 (76%) also completed a submission for the random prize draw survey. Most participants practised in either Melbourne or Sydney, Australia’s two largest cities. The demographic and caseload features of the participants are summarised in Table I.

Table I. Participants’ demographic and caseload characteristics (n = 72).

Practice location	Frequency n (%)
Melbourne	19 (26%)
Sydney	18 (25%)
Brisbane	5 (7%)
Adelaide	5 (7%)
Perth	3 (4%)
Geelong	3 (4%)
Wollongong	2 (3%)
Albury	2 (3%)
Other	15 (21%)
Work setting^a
Private practice	43 (43%)
Disability	18 (18%)
Department of Education and Child Development^b	17 (17%)
Hospital	10 (10%)
Community health	5 (5%)
Non-Governmental organisation	2 (2%)
Other	4 (4%)
Weekly number of hours working as an SLP
0 to 8 hours	3 (4%)
9 to 20 hours	11 (15%)
21 to 37 hours	33 (46%)
38 or more hours	25 (35%)
Estimated weekly number of hours spent in client consultations
0 to 8 hours	8 (11%)
9 to 20 hours	38 (53%)
21 to 37 hours	25 (35%)
38 or more hours	1 (1%)
Estimated proportion of NDIS-funded clients on current caseload
0–29%	9 (13%)
30–69%	22 (31%)
70–100%	41 (57%)
Length of time working with NDIS-funded clients
Less than 1 year	3 (4%)
1 to 3 years	36 (50%)
4 to 6 years	29 (40%)
7 or more years	4 (6%)

Note. As a result of the rounding process, some columns may not always add to 100%.

^aSpeech-language pathologists were asked to select all applicable options.

^bThis wording was used as an umbrella term for all Departments of Education in each state.

Data analysis

Data from the survey were downloaded from Qualtrics to be used with Jamovi (The Jamovi Project, 2020) for quantitative analysis and NVIVO (QSR International, 2020) for qualitative analysis. Participants were asked to rate their level of agreement with Likert scale statements in regards to the NDIS-funded paediatric speech and language intervention they have conducted. At the time of data collection, it was likely that some intervention sessions were run via telehealth due to the COVID-19 pandemic, which may have influenced how SLPs engaged with parents. To minimise this influencing results, participants were asked to respond to these statements in relation to the context in which intervention was typically conducted, such as through face-to-face consultations. Responses to the statements were tallied and converted to percentages. To determine an average score of participants’ use of practices relating to family-centred service delivery models, statements were labelled a number from 1 to 5 (1 = strongly disagree and 5 = strongly agree). Not applicable answers were excluded from calculations.

Participants were asked to provide demographic and intervention information for up to three most recently seen paediatric clients whose speech and/or language intervention was funded by the NDIS. The purpose of this was to scope the demographics of children accessing speech and/or language intervention through NDIS funding and what type of interventions were being provided, as a context for the study. Of the 106 clients represented in this study, 100 were reported to receive language intervention and all 106 were reported to receive speech intervention.

More than one choice was able to be selected for questions pertaining to communication disorder, speech intervention conducted, and language intervention conducted.

Demographic characteristics of participants most likely to be associated with practices supporting parent involvement were examined for their association with each Likert scale statement response. Characteristics included work location, work setting, weekly number of hours working as an SLP (both in total and within client consultations), estimated proportion of NDIS-funded clients on the participant’s current caseload, and number of years working with NDIS-funded clients for speech and/or language intervention as an SLP. For continuous data, the Spearman coefficient was used. For categorical data where there were two different groups, Mann-Whitney U tests were used. Mean differences were calculated, for example, mean response scores of participants who did not work in the examined workplace setting were subtracted from mean response scores of participants who stated they did. Positive mean differences indicated that participants who did not state they worked in the examined workplace setting had higher mean average scores than those who stated they worked in the examined workplace setting. As the dependant variables (i.e. each Likert scale question) were not normally distributed, data analysis only used statistical tests for non-parametric data. The significance level (α) was chosen to be 0.05, however, as 40 statistical tests were conducted, a Bonferroni adjustment was used giving a significance level of p = .001. This adjustment was implemented in order to minimise the potential for a Type I error to occur, as a high number of statistical tests were conducted (Armstrong, 2014).

Responses to the open-text questions were analysed, using the reflexive thematic analysis framework as outlined in Clarke et al. (2015), collaboratively by the first and second authors. The first and second authors are both qualified and experienced paediatric SLPs, who are Australian European and NZ European respectively. Neither are parents of children who have received speech/language intervention services. The authors followed the six-phase analytical process as consistent with Clarke et al. (2015). After familiarisation with the data, codes were developed and applied to responses. Codes and themes were generated from responses to individual questions. This allowed for specificity of SLPs’ practices to be maintained, as themes were able to represent specific aspects of parent involvement rather than SLPs’ practices of parent involvement in general. Additionally, each response may have had information categorised under multiple codes, and so the number of coded responses was higher than responses collected for each question. If a new code was generated part way through exploring responses, responses that had already been coded were revisited to see if they were relevant to the newly-generated code. As responses ranged in length of 1–4 sentences and were descriptive in nature, semantic coding (i.e. identifying explicit, surface-level meanings) was primarily used over latent coding (i.e. identifying underlying ideas and assumptions). Once coding had been finalised, themes were generated in order to categorise all codes that contained meaningful responses. These themes were then reviewed and refined to reflect the interpretation of both authors.

Result

Clients

Of the clients represented in the data, 53% were identified as having more than one communication disorder or disability. Participants reported that 50% of children represented received intervention for SSD. Of the children represented, 40% were identified as receiving more than one type of speech sound intervention. Participants also reported that 89% of children represented received intervention for language disorder. Of the children represented, 63% were identified as receiving more than one type of language intervention. Data for these clients are summarised in Table II.

Table II. Participant-reported client characteristics.

Sex (n = 106)	Frequency n (%)
Male	69 (65%)
Female	37 (35%)
Age (n = 105)
0 to 2 years	11 (10%)
3 to 5 years	44 (35%)
6 to 8 years	24 (23%)
9 to 11 years	13 (12%)
12 to 14 years	8 (8%)
15 to 17 years	5 (5%)
Communication disorder/disability (n = 188)
Autism spectrum	50 (27%)
Speech sound disorder	47 (25%)
Developmental language disorder	39 (21%)
Intellectual disability	18 (10%)
Global developmental delay	17 (9%)
Cerebral palsy	3 (2%)
Deaf/hard of hearing	3 (2%)
Other	10 (5%)
Unsure	1 (1%)
Speech sound disorder intervention conducted (n = 205)
Cued articulation	30 (15%)
Phonological awareness	25 (12%)
Minimal opposition contrast	22 (11%)
Traditional articulation	19 (9%)
Auditory discrimination	16 (8%)
Auditory bombardment	16 (8%)
Core vocabulary	13 (6%)
Maximal opposition contrast	7 (3%)
Other	7 (3%)
I did not provide speech intervention for this client	50 (24%)
Language intervention conducted (n = 263)
Semantics and vocabulary	68 (26%)
Syntax and morphology	49 (19%)
Narrative and other forms of discourse	38 (14%)
Phonological awareness	27 (10%)
Metalinguistics	25 (10%)
Reading comprehension	16 (6%)
Social communication	9 (3%)
Augmentative and alternative communication	7 (3%)
Early language and play intervention	7 (3%)
Pre-linguistic communication	4 (2%)
Other	2 (1%)
I did not provide speech intervention for this client	11 (4%)

Perceived practices of parent involvement

Participants were asked to rate their level of agreement for eight statements on a 5-point Likert scale (where 1 = strongly disagree and 5 = strongly agree, and not applicable answers were removed from calculations) that centred around parent involvement within their typical intervention practice (see Table III). The majority of responses to each statement were agree or strongly agree. The mean average score for all statement responses was 4.44 (range = 4.15–4.59). One statement had 10 “not applicable” responses: “I provide information to parents/caregivers so they are made aware on what has been happening in intervention sessions in which they are not present.” Open-text responses for these participants were examined. Five indicated that parent attendance was mandatory or expected, and five stated that parents were always present.

Table III. Participant agreement on statements of parent involvement in intervention.

Statement (n = 72)	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Not applicable	Average
I encourage parents/caregivers to be present during my intervention sessions	1 (1%)	4 (6%)	6 (8%)	13 (18%)	48 (67%)	0 (0%)	4.51
I encourage parents/caregivers to be involved in the work and activities conducted in my intervention sessions	2 (3%)	3 (4%)	6 (8%)	20 (28%)	41 (57%)	0 (0%)	4.41
I typically set home activities for parents/caregivers to complete with their children between intervention sessions	2 (3%)	2 (3%)	13 (18%)	18 (25%)	37 (51%)	0 (0%)	4.28
I typically follow up on home activities to assess the progress their child has made on these activities outside of intervention sessions	0 (0%)	4 (6%)	9 (13%)	30 (42%)	29 (40%)	0 (0%)	4.15
I involve parents/caregivers in goal-setting discussions for their child’s intervention	2 (3%)	2 (3%)	7 (10%)	15 (21%)	46 (64%)	0 (0%)	4.5
I provide information to parents/caregivers so they are made aware on what has been happening in intervention sessions in which they are not present	1 (1%)	0 (0%)	5 (7%)	16 (22%)	40 (57%)	10 (14%)	4.58
I allow parents/caregivers the choice to engage in correspondence (e.g. through email or phone) outside of intervention sessions so they are able to ask questions and provide information relating to their child’s intervention	2 (3%)	2 (3%)	6 (8%)	16 (22%)	46 (64%)	0 (0%)	4.49
If the parent/caregiver attends the session, I allow some time to discuss details relating to the intervention (e.g. the plan of the day’s intervention, intervention progress, feedback from parents relating to intervention)	1 (1%)	2 (3%)	4 (6%)	16 (22%)	49 (68%)	0 (0%)	4.59
Totals and averages	11 (2%)	19 (3%)	56 (10%)	144 (25%)	336 (58%)	10 (2%)	4.44 (avg)

Characteristics of SLPs that influence parent involvement in NDIS-funded intervention

Five demographic and caseload characteristics of participants were tested for significance against the average responses to each Likert scale statement (listed in Table III). These characteristics included work location, work setting, weekly number of hours working as an SLP (both in total and within client consultations), estimated proportion of NDIS-funded clients on the participant’s current caseload, and the number of years working with NDIS-funded clients for speech and/or language intervention as an SLP. The complete analysis can be found in Tables 6 to 13 in the Supplementary Material. Statistically significant and relevant non-significant results following Bonferroni’s correction are summarised here.

Firstly, participants who worked in the Department of Education (DE) had a significant Mann-Whitney U score when compared to participants who did not for Statement 1 (i.e. encouraging parent attendance; U = 241, mean difference = 0.76, p <.001), Statement 5 (i.e. involving parents within goal-setting discussions; U = 249, mean difference = 0.74, p = .001), Statement 6 (i.e. providing information regarding consultations to parents not present; U = 187, mean difference = 0.71, p <.001), and Statement 8 (i.e. allowing time for discussion of session plans within consultations; U = 182, mean difference = 1.00, p <.001). There was no significant Mann-Whitney U score for Statement 3 (i.e. setting home activities; U = 278, mean difference = 0.69, p = .009) and Statement 4 (i.e. following up on home activities; U = 377, mean difference = 0.28, p = .278). Positive mean differences indicate that those who worked in the DE had lower average scores for Likert scale statement responses when compared to those who did not work in the DE.

Secondly, the number of years providing intervention for clients with speech and/or language disorders as an SLP was significantly positively correlated with Statement 3 (i.e. setting home activities; r_s = .417, p = <.001).

Barriers to and facilitators of parent involvement

Responses indicated that there were perceived barriers to further parent involvement within the NDIS-funded speech and/or language intervention for SLPs’ discussed clients. Table IV illustrates themes, codes, and example quotes from participants relating to barriers to parent involvement.

Table IV. Participant responses relating to barriers to parent involvement in intervention.

Themes and codes	Example quote corresponding to code
Working within a school	“Therapy at school is always a barrier to more intensive involvement in intervention.” (Participant 16)
Lack of confidence or not feeling comfortable to involve parent/caregiver in intervention	“I lacked the confidence in my own clinical skills, which made me less likely to involve the parents and more likely to want to do the intervention myself.” (Participant 48)
Insufficient time capacity of parents	“The parents both work full time and have limited capacity/time to implement strategies provided.” (Participant 11)
Parents not agreeing with, understanding, or believing in intervention methodology	“That parents think we as SP are responsible for all progress and they are no experts and therefore should let me do all the activities.” (Participant 61)
Parents choosing not to be engaged in service delivery	“Mum appears disengaged and wants time to herself so drops off her daughter to sessions.” (Participant 52)
Parent not being able to be involved in intervention due to personal factors	“Mum’s capacity for new information and her own mental and physical health conditions.” (Participant 2)
Language and cultural differences	“Family is CALD, and Mo’s English is very good but not perfect, and she sometimes has difficulty explaining concerns to me.” (Participant 10)
Parent involvement is not appropriate with specific child	“The child doesn’t like to work with the mother in the room and works best when the mother is either not in the room…” (Participant 52)

Participants were asked what facilitated parent involvement in intervention. Participant responses communicated aspects of service delivery that facilitated parent involvement. Table V summarises the themes, codes, and example quotes from participant responses.

Table V. Participant responses relating to facilitators of parent involvement in intervention.

Themes and codes	Example quote corresponding to code
Collaborative and open communication with parents	“Open communication has been the most important aspect” (Participant 9)
Encouraging family attendance and participation within intervention	“Using activities that another adult is needed, directly ask to join” (Participant 58)
Building a professional relationship with parents	“Building a relationship of trust with the parents” (Participant 48)
Adapting session information or content to facilitate communication with parents	“Providing very clear and simple explanations for therapy strategies, discussing things repeatedly and providing information in multiple forms e.g. Verbally, written” (Participant 2)
Adapting session times or settings to suit parent	“Sessions during school holidays when parent has more time and space to be able to engage in therapy.” (Participant 2)
Organisational policy that requires parents to attend consultations	“It’s helpful that my company policy is that a parent needs to be in the room, so I don’t have to convince them to come in.” (Participant 10)
Parents who are willing to be involved in service delivery	“Natural inclination of the parent to be heavily involved, and willingness/desire to work on things at home” (Participant 13)
Parents being adaptable	“This family is happy to try anything which makes things easy.” (Participant 63)

Discussion

The purpose of this study was to explore SLPs’ practices of parent involvement in NDIS-funded speech and language intervention. The majority of respondents indicated a strong commitment to involving parents within intervention. More experienced SLPs used more family-centric practices and DE-based SLPs used fewer. Barriers were found to arise from SLP, parent, and workplace setting characteristics. Facilitators included communication and rapport building, utilising a family-centred model of service delivery, and parent characteristics. In this discussion, the results are outlined and compared with relevant previous literature. The study’s limitations are also stated, and clinical implications and directions for future research are outlined.

Reported use of practices that aim to facilitate parent involvement

The high number and consistency of agree and strongly agree responses across all provided Likert scale statements suggests that paediatric SLPs believe they utilise a diverse range of practices, which support parent involvement in NDIS-funded speech and/or language intervention. Proportions of Australian SLPs reporting parent involvement in intervention sessions for SSDs have increased over time from 35% (Watts Pappas et al., 2008) to 89% (Sugden et al., 2018). While we did not have the mechanism to separate out speech from language services from the current data, the current results suggest SLPs view parents as integral to the paediatric intervention services, aligning closely with findings in Sugden et al. (2018). This may indicate an increase in the use of family-centred service delivery models in SSD-based intervention provision or an increased awareness of the importance of intensive practice for children with SSD. This may be due to an increase in SLPs’ awareness and use of the family-centred International Classification of Functioning, Disability and Health (ICF; World Health Organization, 2001) over time, as suggested by Sugden et al. (2018). Another recent change is the rollout of the NDIS, a large disability reform within Australia beginning in 2013 (Kendrick et al., 2017). The current study indicates high levels of parent involvement are commonplace in NDIS-funded practice for children with speech/language needs.

Previous research identified that Australian SLPs working with children with SSDs were reported to always or usually encourage parents to observe and get involved within consultations (McLeod & Baker, 2014), and that parents were always or usually present within intervention sessions (Sugden et al., 2018; Watts Pappas et al., 2008). The current study suggests this trend holds for the current SLP participants relating to their practice with NDIS-funded children with SSD and language needs.

The majority of the current participants also agreed or strongly agreed with statements relating to setting and following up on home activities. Relevant previous literature has stated that home practice has been established as the primary strategy SLPs utilise in involving parents in intervention for SSD (McLeod & Baker, 2014; Sugden et al., 2018; Watts Pappas et al., 2008). In the current study, participants reported following up on home activities less often than setting home activities. Similar findings have been identified by Tambyraja (2020), who reported factors such as caseload size may impact on SLPs’ capacity to follow up on home activities previously set. However, in the current study, caseload sizes were not recorded so full comparisons cannot be made.

SLP-related characteristics and barriers that influence parent involvement

Participants who worked in the DE reported they utilised fewer practices to support parent involvement compared with participants who worked in non-DE settings. Participants also detailed in the open-text responses that working within a school was a notable barrier to parent involvement. Similar findings have been reported on in previous literature (Sugden et al., 2018; Tambyraja et al., 2017; Watts Pappas et al., 2008). However, there was no significant mean difference between DE-based SLPs and non-DE-based SLPs for statements relating to setting and following up of home activities. Tambyraja et al. (2017) suggested that for DE-based SLPs, communication with parents was primarily through a homework folder, potentially to save time for both parents and SLPs. A barrier is likely the nature of the workplace itself, as parents are not typically involved in everyday learning activities at school but are seen to be key supporters of homework completion. Literature exploring barriers to parent involvement that DE-based SLPs face has identified workplace barriers, such as inflexible options for service delivery, time constraints, scheduling challenges, and high caseloads (Mandak & Light, 2018; Watts Pappas et al., 2008).

Results from this study indicated a positive relationship between SLPs’ experience and setting home activities. Some open-text responses from participants also highlighted a lack of confidence in their own clinical skills, resulting in the SLP being less likely to involve parents in intervention. Similar studies have found comparable results: More experienced SLPs are likelier to report conducting parent training for home activities (Sugden et al., 2018), and SLPs with more years of experience reportedly feel more comfortable discussing home activities with parents (Watts Pappas et al., 2008). In contrast, Oliveira et al. (2015) found no correlation between parent involvement and years of experience. More experienced SLPs may be able to utilise a wider range of tools and be more confident in a range of areas, such as assigning home activities, when compared with less experienced SLPs. Previous literature has supported this idea, with Roulstone et al. (2012) identifying that experienced SLPs, when compared to newly-qualified SLPs, find translating and applying theoretical knowledge to complex clinical situations to be easier, and Joffe and Pring (2008) finding that confidence of choosing appropriate interventions increased with years of experience.

Parent-related barriers to parent involvement

The majority of barriers to parent involvement that SLPs reported were parent centred. Similar research has found SLPs facing parent-related barriers of parent capability, availability, and attendance at sessions (Sugden et al., 2018).

Some participants reported that parents resisted engagement within intervention and did not agree with the intervention methodology provided. SLP participants in previous research have stated that parents’ expectations regarding their role in intervention was a barrier they had faced when aiming to incorporate parent training (Sugden et al., 2018). While SLPs reported parents’ disagreements as the problem, it is likely parents may see the problem lying in limited service options or the SLP. Parents may disengage from intervention when their preference does not align with the SLP’s and may not feel comfortable initiating discussions about this with the SLP (Watts Pappas et al., 2016). SLPs who wish to involve parents in intervention should collaborate with parents to identify solutions to misalignments in preference of intervention (Mandak & Light, 2018).

Facilitators of parent involvement

Regarding facilitators of parent involvement in intervention, participants wrote of encouraging collaborative communication with parents. Research has reported that parents can value collaborative discussion (Carroll & Sixsmith, 2016; Forsingdal et al., 2014), and SLPs see this practice as a pathway to individualising service delivery to families (King et al., 2015) and increasing parent involvement in and satisfaction of intervention services (Glogowska & Campbell, 2004; Sugden et al., 2019). Participants within the current study had similar reports to the literature discussed, citing that open communication helped facilitate parent involvement.

Participants stated that encouraging parent attendance and engagement in session activities was seen to establish a team-based framework. Parents who are supported by SLPs to take a more active role can increase intervention effectiveness (Lawler et al., 2013) and provide useful feedback regarding what is working within service delivery (Edwards et al., 2016). Participants reported that establishing a trusting relationship over time with parents was a facilitator of parent involvement. Previous studies have suggested parents prefer to work with SLPs who showcased positive qualities, such as care, compassion, and friendliness (Auert et al., 2012; Watts Pappas et al., 2016). Similar studies have also shown that SLPs see that having strong relationships with parents can help them anticipate how the parent would interact and engage best in intervention (King et al., 2015).

Parents desire SLPs to provide simple, jargon-free information related to intervention (Edwards et al., 2016; Watts Pappas et al., 2016); a practice reported to empower parents and support their ability to make informed decisions (Auert et al., 2012). SLPs within the current study provided similar viewpoints, stating that providing simplified information regarding intervention strategy can facilitate parent involvement.

Participants suggested altering service delivery practices, such as allowing parents to choose a convenient time and location for sessions, supported parent attendance. DE-based participants stated that barriers to parent attendance at school consultations could be mitigated by working with schools to allow for parents to be on-site during intervention and consulting with parents during school holidays. Literature has stated that parents value SLPs’ flexibility with consultation times, and both parents and SLPs see fitting intervention into families’ routines as an important aspect of intervention service delivery (Carroll & Sixsmith, 2016; McAllister et al., 2011).

Finally, SLPs perceived parent characteristics of being self-motivated, willing to be engaged with session activities, and holding a proactive and flexible attitude to their own involvement as facilitators of increased parent involvement. Previous literature has identified that parents are motivated to be involved in services when the service provider showcases care and commitment to the child, and when the child enjoys and makes progress throughout intervention (Phoenix et al., 2020). Parents who hold a perception of ownership and empowerment can be active participants within their child’s intervention (Forsingdal et al., 2014). These suggestions may indicate that the SLP can be a catalyst for parents’ motivations to be involved in intervention.

Limitations

Limitations of self-reporting, social desirability bias, and recall bias were identified. Due to the self-reported survey methodology, it was not possible to determine if information provided matched SLPs’ actual practices. Participants may have over-reported particular clients in which parent involvement had been easier to facilitate and under-represented client experiences where parent involvement had not been sought. Participants may also have under-reported barriers to parent involvement centred around themselves, compared with their reporting of parent-related barriers. The context around parent participation is important to consider as parent participation in intervention varies by age, stage, and intervention targets, with a shift to more school-based and teacher training over time (Roulstone et al., 2012); however, it was beyond the scope of this study to consider these factors. Rather, this study provides a general overview of SLPs’ perceptions of parent involvement within NDIS-funded speech-language pathology services for children. This study asked participants to report on practices with one to three most recently seen clients. Alongside this, the study was also conducted early in the COVID-19 pandemic and participants were asked to report on typical service delivery practices (i.e. not modified in response to the pandemic, such as moving intervention sessions to telehealth). As a result, participants may have had difficulty recalling this information. Finally, participants may have also not been aware of which intervention was NDIS-funded and thus some responses may have not been exclusively relatied to NDIS-funded clients. While the survey was only distributed to relevant networks, organisations, and Facebook groups, participant anonymity did not make it possible to verify that all participants were certified SLPs.

Clinical implications

This study has illustrated that parent involvement is commonplace with the study’s sample in NDIS-funded speech and/or language intervention. There was no support for the proposition that a move to a business model has limited parent engagement in the current data, instead it may have facilitated it by increasing parent choice and decision-making power. However, DE-based SLPs reported use of fewer practices that include parents than those working in other settings. The current study suggests use of facilitators, such as increased correspondence with parents, flexible scheduling of appointments, making an effort to build rapport, as well as incorporating home activities within intervention, may help increase parent involvement in school-based intervention. Social distancing measures were present at the same time as this study was conducted, due to the COVID-19 pandemic. We specifically asked SLPs to consider typical clinical practice when writing their survey responses and not report on clinical practice modified to incorporate social distancing, such as using telehealth. However, what is considered “typical practice” may have since changed in a post-COVID-19 world, most likely through higher use of telehealth. Increased use of videoconference calls with parents during sessions may be a helpful solution for facilitating parent involvement in school-based intervention.

SLPs should consider how parents view the hierarchy of leadership and decision-making abilities within service delivery, and aim to facilitate regular discussions with parents to explore benefits of their involvement within intervention. This may lead to an increase in parents’ satisfaction of and engagement with the intervention provided (Glogowska & Campbell, 2004).

A higher number of parent-related barriers compared to SLP-related barriers to parent involvement was identified. This suggests that SLPs may not have reflected on their own service-delivery practices as deeply as they reflected on parent characteristics and behaviours. Overall, this study highlighted the need for improved research into the collaborative process between parents and SLPs, such as the realist evaluation process proposed by Klatte et al. (2020).

Future research

Further exploratory research around individualised funding models (such as the NDIS) and how they influence change in service delivery are important to guide policy-making decisions. The current results should be replicated by studies of actual practice, rather than self-reported practices. Specific components of SLPs’ collaborative practice recommended to be explored are the context around individual children that contributes to successful collaborative partnerships with parents, the mechanisms of change for different client needs (including dosage/intensity of supports), parents’ perceptions of their collaboration in NDIS-funded speech-language pathology intervention, parents’ views on NDIS-funded speech-language pathology services, and how these factors impact on child outcomes (Klatte et al., 2020).

Conclusion

Findings from this study indicate that NDIS-funded SLPs’ services for children with speech and language needs are strongly family-centric. More experienced SLPs reported using more family-centric practices and DE-based SLPs used fewer. The vast majority of barriers to parent involvement were reported to be parent-centric. Participants believed that communication and rapport building with parents, utilising a family-centred model of service delivery, and parent characteristics facilitated parent involvement.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1 Terminology has been simplified by using parent to encompass parent, carer, caregiver, family, etc. (except for when contextually appropriate).