A scoping review of virtual synchronous intervention studies in preschool rehabilitation

Abstract 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. Implications for Rehabilitation The COVID-19 pandemic has increased the need for effective, evidence-based virtual interventions. This study summarizes the available literature to support preschool rehabilitation clinicians in making decisions about virtual interventions. Data presented can inform clinical decisions about technology to use, session length and frequency for various disorders, and activities used to engage preschoolers in the virtual environment.


Introduction
With the rapid shift to virtual service delivery during the COVID-19 pandemic, rehabilitation health professionals, including Speech-Language Pathologists (SLPs), Audiologists (AUDs), Physical Therapists (PTs), Occupational Therapists (OTs), and their associated rehabilitation health assistants had to quickly transition to working virtually with children and families.Virtual interventions were provided globally and offered an opportunity for rehabilitation health services to continue remotely during pandemic-related lockdowns and stay-at-home orders [1,2].The delivery of virtual services was particularly critical for early interventions, which are known to significantly impact children's developmental outcomes [3,4].Instances of virtual services increased by approximately 150% during the COVID-19 pandemic [5], despite a lack of evidence to guide best practices for virtual delivery in pediatric rehabilitation.There was however a significant need for clinicians to understand how interventions could be delivered, particularly for preschool aged children for whom published studies were particularly sparse.
Even before the COVID-19 pandemic, an alternative to in-person care was telehealth or telemedicine services, which were typically used to provide healthcare to those in remote and hard to reach communities, or those who had difficulties attending in-person appointments due to accessibility issues [6].Additionally, virtual care provided flexibility and convenience for families who would typically travel long distances to access services [7].Historically, telehealth referred to phone-based intervention, for which there was verbal communication between patient and provider, with a lack of face-to-face interaction [8].There are also a number of internet-based interventions that use pre-recorded, video-based sessions to deliver services remotely [9].These types of interventions differ greatly from those delivered via video-conferencing software during which interactions are synchronous [10].Similarly, Virtual Reality (VR) technology may be delivered synchronously with augmented feedback [11], however, interventions delivered in a face-to-face format, such as videoconferencing, facilitate real-time interactions with both audio and visual cues available.Compared to video playback methods, synchronous delivery provides an opportunity for real-time feedback and the potential for high quality interaction [10,12].It is therefore critical to consider synchronous and asynchronous virtual interventions as separate entities in terms of service delivery options.Telehealth services can differ greatly in their meaning, both across and within the rehabilitation health disciplines, therefore the following definition from Shaw and colleagues [11] was used to guide this review: "any interaction between patients and/or members of their circle of care, occurring remotely, using any forms of communication or information technologies, with the aim of facilitating or maximizing the quality and effectiveness of patient care".
Many literature reviews have addressed the use of virtual health services in regard to patient satisfaction and rural and urban service delivery, when delivering services to adults [13][14][15].Studies have also reported considerations for using virtual services in pediatric populations, although these are largely focused on services for school-aged children [16,17].Some studies have looked at preschoolers and school-aged children together, making it difficult to separate the two populations [18,19].Little is known about how allied health professionals deliver virtual services to preschoolers, and the approaches and strategies used to engage preschoolers are likely to differ from those used to support school-aged children [20].As an example, preschoolers may be particularly challenging to engage in the virtual environment due to factors such as attention, emotional reactivity, and desire to control their environments [21,22] and they may therefore require the use of specific strategies to participate fully in virtual interventions.It is also critical to understand how outcomes are measured during virtual interventions, as it is important to ensure tools are evidence-based and accurately reflect the impact of virtual interventions.Clinicians are required to measure and document the impact of their services [22], but little evidence exists for how this can be achieved during interventions that are entirely virtual.
A scoping review provides a methodology for summarizing the existing literature on a specific topic and highlighting knowledge gaps to be addressed in future research [23,24].In a scoping review, the goal is to map and synthesize findings [23].The aim of this scoping review was to explore the published literature on virtual interventions delivered by rehabilitation health professionals that either targeted preschool-aged children directly, or indirectly by coaching their parents to facilitate their child's development.The review was designed to summarize the published approaches, methods, and tools to inform the delivery and measurement of such virtual intervention services.

Methods
This review focused on clinician-led studies delivered in a face-toface synchronous manner and used the methodology described by the Joanna Briggs Institute [25].The JBI framework was developed based on foundational frameworks by Arksey and O'Malley [26] and Levac and colleagues [27] and is recognized as an effective guideline for conducting a high-quality scoping review [28,29].(g) included primary data (e.g., not a study protocol, review, or commentary).For the purposes of the review, rehabilitation health professionals included PT, OT, SLP, AUD, and their associated rehabilitation assistants as they were the most common professionals to deliver rehabilitation interventions with preschoolers in Canada where this study was conducted.To ensure all relevant studies were identified, no pre-determined database-specific limits were applied to year of publication, age of child participants, or research design for the initial search.Grey literature was not included in this review as the goal was to identify studies that had been peer-reviewed and presented empirical data to support their application in a synchronous virtual environment.Studies were not limited by research design.Case studies, multiple groups design, exploratory studies, and randomized control trials were all eligible for inclusion.Two authors (KH, DT) independently completed both title and abstract review and full text screening using Covidence software [30].To ensure initial reliability between screeners, ratings were compared for a random sample of 10 citations for both the title and abstract and full-text review stages.Data extraction for all factors was completed for each included study by both coders (KH, DT).Similar to the process for article screening, conflicts related to data extraction were discussed until agreement was reached.v. Collating, summarizing, and reporting the results: Findings were synthesized quantitatively (i.e., with frequency counts) and qualitatively and grouped into six categories.vi.Consultation with clinicians: When developing the research questions, we consulted with five clinicians to understand their questions about virtual service delivery.Practicing clinicians in SLP and PT who were known to the research team were engaged via email and asked to share their clinical questions regarding virtual service delivery with preschoolers and explain how a study on virtual intervention could best support their practice.Questions were assessed to identify common themes, with the primary ones being related to methods for delivering and measuring the impact of virtual interventions.This information was then used by the research team to develop the research question and protocol for this review.Information shared by clinicians was used to develop the research questions and protocol for this review.

Results
The search yielded a total of 6,647 studies.The removal of 2,445 duplicates left 4,202 studies for title and abstract screening.After title and abstract screening, full texts were screened for 57 studies, and 16 were included in the review (see Figure 1).Results within each data extraction category are presented below.Articles was assessed using the Oxford Centre for Evidence-Based Medicine (CEMB) for levels of evidence (Table 2).Most studies were case series (n ¼ 7, 44%), while the remainder were cohort studies (n ¼ 5, 31%), and randomized trials (n ¼ 4, 25%).

Technology
Several videoconferencing platforms were used to deliver virtual intervention services.Skype was used most frequently (n ¼ 5, 31%), followed by Zoom (n ¼ 3, 19%).Other studies (n ¼ 7, 44%) reported the use of videoconferencing software, but did not name it (e.g., 'online videoconferencing', 'PC-based videoconferencing'), and one reported the use of four different softwares (Facetime, Movi, Zoom, and Vidyo) [31].Two studies did not report any information on the technology platform they used.
Many studies reported using technological features in addition to their videoconferencing software to facilitate their virtual interventions that involved asynchronous components for monitoring outcomes and/or communication with families.Two used a program to video record intervention sessions, and the recording was provided as a learning tool for families.One study posted an online video of the exercises children did in a virtual session so it could be referred to later.Other features included the use of a webcam and document camera to show materials such as word cards, a phonology software to help children differentiate phonemes (Sound Contrast in Phonology; SCIP), [32] and patients taking and uploading photographs (software unspecified) so therapists could monitor posture outside of sessions to compare pre-and post-intervention.In parent-training programs, Microsoft PowerPoint was used to present intervention content to parents in real-time [33], and via printed copies of slides [34].Other features included: (a) the use of 'e-helpers' (e.g., additional support staff on the videoconferencing call) to troubleshoot technology issues [35], (b) the use of screen recording software to provide families with the session information as a reference [36], and (c) the addition of a transcription service to increase accessibility by presenting captions in real-time during the intervention session [37].All of these features were reported, but it should be noted that their effectiveness was not assessed.More information can be found in Table 3.

Discipline and mode of delivery
Most included studies fell within the scope of SLP (n ¼ 14, 88%).Remaining studies were within the scope of PT (n ¼ 1, 6%) or OT (n ¼ 1, 6%).Many interventions were child-focused (n ¼ 9, 56%), but some were parent-focused (n ¼ 6, 38%), or both child-and parent-focused (n ¼ 1, 6%).All 16 included studies which involved one-on-one interventions, however one reported combining individual and group-based sessions for children with articulation, language, and/or fluency disorders [35].Across studies, most virtual interventions (n ¼ 14, 88%) were delivered by clinicians.Two studies reported a combination of parent-and clinician-administered intervention, with clinicians first teaching intervention techniques and then providing parents with feedback on their use of the techniques.Two studies [35,38] were conducted at remote sites set up to deliver telehealth services with pre-determined technology, while the rest were conducted from the client's home (see Table 3).Remote sites helped eliminate some of the challenging factors associated with conducting virtual therapy from the client's home (e.g., noise, other family members, etc.).

Timing
Session length was reported in 13 studies (81%) and ranged from 15-90 min (range ¼ 30-60 min).Session frequency was reported for 14 studies (88%), and most sessions occurred on a weekly basis (n ¼ 11, 69%).Other studies reported more frequent sessions, including twice per week for children with severe phonological disorders (n ¼ 1, 6%), five times per week for those with childhood apraxia of speech (n ¼ 1, 6%), and every two weeks for  [38] Case series 4 Sobierajska-Rek et al. (2020) [58] Case series 4 those enrolled in Auditory-Verbal Therapy, which targeted children's language detection and production skills (n ¼ 1, 6%).Few studies reported the duration of the intervention in its entirety, but those that did noted services ranging from weekly for a 3month period to weekly for an 8-month period.Children in the Lidcombe program (targeting stuttering) advanced through the program's stages on their own trajectories, while those with childhood apraxia of speech (targeting motor speech production) received services for approximately 5 months, and those in Auditory-Verbal Therapy (targeting language) were enrolled in programming for approximately 2 years.Day of the week and time of day were not consistently reported, but three studies did note that sessions occurred in the evenings/after school on weekdays.

Engagement
Many studies reported using an activity or engagement strategy during their virtual intervention (n ¼ 11, 69%).Example activities included playdough, blocks, toys, bubbles, board games, specific toys that corresponded to characters in a book, and both climbing and descending stairs.Specific engagement strategies that were taught to parents during virtual intervention sessions included imitation and creating authentic contexts to support and elicit children's communication, such as embedding intervention within everyday activities and contexts [39].Nearly all studies (n ¼ 14, 88%) noted the use of a parent to keep the child engaged in virtual therapy activities.Parents were involved in two ways: 1) for program improvement or evaluation and 2) to learn how to engage in communicative interactions with their child.Within the first category, parents were asked to report on their satisfaction and perceptions of the intervention (e.g., completing a questionnaire).For example, in one study, parents were to reflect on the quality of videoconferencing, equipment and their general interactions with the service provider.Within the second category, parents learned interaction strategies, to establish engagement, facilitate communication, and create interactive play opportunities.Parents were also asked to demonstrate use of the strategies they learned to ensure they could use the skills outside of the structured therapeutic setting.Additionally, parents were involved in goal setting, providing supplies for activities, and facilitating use of technological platforms.Very few studies (n ¼ 2, 12%) reported the use of specific behaviour management techniques, but those that did noted the use of breaks when needed and dedicated time for parents to practice motivating their child during the intervention session.

Measurement
All included studies reported the use of measures to assess progress during their virtual intervention.Some studies used wellknown norm-referenced/standardized measures including the Preschool Language Scales (PLS-4) [40] and Goldman-Fristoe Test of Articulation (GFTA-2) [41].Others used criterion-referenced outcome measures, including the Canadian Occupational Performance Measure (COPM-2) [42], the Assessment of Preschool Children's Participation (APCP) [43], the North Star Ambulatory Assessment (NSAA) [44], and informal measures (e.g., percentage of syllables stuttered, initiations per minute, responses per minute, and percentage of phonemes correct).Finally, the MacArthur Bates Communicative Development Inventory (MCDI) [45] was used as a parent-report measure of children's early language skills.

Discussion
This review aimed to summarize the literature on virtual interventions in the preschool rehabilitation literature to describe the various technologies, approaches, features, and techniques that have been used by rehabilitation health professionals.The review expands upon a previous review that explored pediatric telehealth delivery more widely [18], by narrowing the focus on preschoolers specifically to support clinicians working with this population.Findings will be useful for clinicians wanting to explore existing virtual features and engagement and measurement strategies, and to estimate the appropriate structure for the interventions they deliver.Differences were observed in how technological platforms and features were used, the ways in which children were engaged in intervention, and how change during virtual interventions was measured.Several platforms were reported in the delivery of virtual intervention, not all of which were 'mainstream', suggesting there are alternate options that may be useful for clinicians.The engagement strategies identified may be useful for clinicians in determining how to best interact with clients in a virtual environment.In conducting the literature search, several tutorials outlining 'Tips & Tricks for Engaging Children Virtually' and 'How to Conduct Interventions with Preschoolers Virtually' were identified, but these were anecdotal and not tested empirically.Change was measured across all studies, using tools similar to those used for in-person therapies, suggesting it is feasible for clinicians to incorporate both standardized and criterion-referenced assessment tools as part of their virtual interventions.
Scientists in the rehabilitation health fields conduct research that is intended to improve, support, and guide practice.In order to be impactful and meaningful, this research should involve end users in the process [46].Our review acknowledged the importance of end user input by including the optional sixth step of scoping reviews, consultation [27], which helped to narrow the focus of our review on the issues most pressing for clinicians.
While we have summarized data that may be useful to clinicians, this review also highlights knowledge gaps related to virtual interventions for preschoolers.There were many variables of interest for which data were not available or widely reported, including intervention duration and how technological features (Microsoft PowerPoint slides, screen recording software, etc.) were used during virtual services.Further data to support decisions related to virtually delivered interventions are needed to help clinicians engage children and their families in interventions with an evidence-based dose and in an evidence-based way.For clinicians looking for clinical practice guidelines on the delivery of virtual care, Glista and colleagues [47] have developed evidencebased recommendations geared to hearing healthcare professionals.
There were some gaps, but much of the information we were seeking was clearly presented in the literature.For example, at least one measure of child outcome was used in each included study.While we assume measurement tools were well aligned with the goals of intervention, it should be noted that we were unable to confirm how well the identified tools aligned with specific intervention targets as most studies did not explicitly state the goal(s) of their intervention.In those studies that compared virtual and in-person interventions (i.e., those focused on stuttering or language growth for children with hearing loss), no significant differences in outcomes were reported, suggesting virtual interventions may be as effective as those delivered in-person, although a direct comparison was outside of the scope of this review.We have highlighted several measurement tools that may be useful for clinicians working virtually but note that additional research is needed to compare and validate these tools for use in the virtual environment.
Similarly, we identified resources, features, and methods associated with six factors of interest, although the included studies did not evaluate the effectiveness of those factors directly.Additional research is needed to investigate the impact of the six factors (i.e., demographics, technology, mode of delivery, timing, engagement, measurement) during virtual interventions.For example, studies comparing technology types, child versus parent-directed virtual interventions, and individual and group-based interventions would provide valuable effectiveness data.Similarly, manipulations of session frequency, length, and duration would provide evidence to support decisions about resource allocation for virtual services.

Limitations and future directions
One limitation to this review was that the majority of included studies were SLP focused, which may limit generalizability for clinicians within other rehabilitation fields.However, many findings were relevant across disciplines, particularly those that addressed engagement in the virtual environment and the use of technological features.Another limitation was the differences in reporting of the variables of interest across studies.For example, the type of impairment being targeted in intervention differed across studies (e.g., speech fluency, childhood apraxia of speech, and language), making it difficult to generalize findings.Furthermore, there were large gaps in reporting regarding session length, outcome measurement, and intervention format (e.g., child-versus parent-focused, individual versus group-based).More comprehensive reporting is needed to support preschool rehabilitation health professionals in knowing which virtual intervention types and formats may be more or less beneficial for different groups of children.Additionally, it is important to identify the facilitators and barriers to virtual interventions, particularly for those targeting preschoolers where evidence is lacking.Evaluation of the implementation barriers associated with virtual interventions would support clinicians wanting to implement them in practice [48].Similarly, the development of additional digital assessment and intervention tools could support clinicians in better delivering and assessing the impact of their virtual services [49].A final limitation is the timing of this review.With the rapid shift to virtual service delivery during the COVID-19 pandemic, there is likely to be an influx of research on the delivery of virtual interventions in preschool rehabilitation in the coming years, therefore, this review should be updated to incorporate new findings in the future.
We have summarized and synthesized data from published studies on preschool virtual interventions and identified elements of virtual interventions that could be evaluated in future research.For clinicians, these data can serve as a practical guide to assist in decision-making when delivering virtual interventions.For researchers, the review can serve as a framework of factors to consider in virtual intervention studies.For example, Kwok et al.'s [1,50] studies provide clinicians' and parents' perspectives following the provision of virtual care.Clinicians described the ability to be flexible and adapt on the spot, as being critical skills for virtual service delivery.They also stressed the importance of modifying goals and collaborating with parents.Similarly, parents reported the need to participate fully and limit or eliminate interruption from external factors so they could focus fully on facilitating the virtual therapy.Parents also expressed satisfaction with virtual services, and appreciated the ability to debrief one-on-one with the clinician following virtual sessions.This paper may be particularly useful supporting clinical decision-making when it comes to the delivery of family-centred virtual services.Clinical resources developed based on the work by Kwok et al. are available online at https://www.canchild.ca/en/resources/356-telepractice-resources.
This scoping review identified the need to continue to conduct research on virtual interventions for preschoolers with an increased focus on effectiveness.Our findings suggest that within the rehabilitation health fields, virtual services focused on speech and language have been the most widely researched, and that these interventions were largely delivered by clinicians one-onone with the child and a caregiver present.Engaging children virtually can be challenging for clinicians, which is why it is helpful, and perhaps recommended, to have a caregiver present who can support establishing and maintaining engagement.Future studies could investigate outcome measurement in the virtual environment to support clinicians in delivering evidence-based virtual interventions.More comprehensive guides on optimal session length and intervention duration are also needed to guide virtual practice.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
The author(s) reported there is no funding associated with the work featured in this article.
Any conflicts were reviewed and discussed until consensus was reached.iv.Charting the data: An extraction protocol was created to extract the following data from all included publications: authors; year of publication; full citation; sample size; child sex; mean age and age range of children; skills being targeted in intervention; biomedical diagnoses and comorbid- ities; technology platform and features used; type of service (PT/OT/SLP/AUD) and who delivered the service (e.g., SLP); parent or child focused intervention; individual or group based intervention; length and frequency of intervention sessions; strategies used for online engagement or behavioural management; and, outcome measurement (Appendix 1).

Table 1 .
Search Categories and Corresponding Search Terms.

Table 3 .
Clinical Reference Guide.